0201-053 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. ,
License # Lic. Class Exp. Date
C -16"i 41�'111014DU 44 0,4C
Date /,ter 4, Signature of Contractor �� ✓ '�� %�"
!� t, -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
I, as owner of the property, or my employees with wages as their sole
compensation,,will do the work, and the structure is not intended or offered for
Sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044,, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by .Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
f �;'P;� �N'•13Al1ii 5�4��374� !�F�
(This section need not be completed if the permit valuation, is for $100.00 or less).
( ) I certify that in the performance of the work for which`this permit is issued,
I shall not.employ any person in any manner so as to become subject to the
workers' compensation laws of California, .and agree that'if; I° should become
Subject fo�the workers' compensation provisions of Section 3700 of the Labor
Code, I sha c rthwith comply with those, provisions.
Date:. f 1 Applicant � :r✓✓w .�� � r fo+
Warning: Failure'to secure Workers' Compensation° coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition'to the cost of compensation, damages.as provided for in Section 3706
of the Labor Code, interest and attorney's fees.,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application -is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
.& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information Is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertyforinspection purposes.
Signature (Owner/Agent)�,� • Jam`' -Date' -
d °1 'F
BUILDING PERMIT PERMIT #
M
DATE VALUATION ° LOT �; ( TRACT
01AiI R./At $3.i148.6
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
.i:AV1 DOILEMAN
'TON'T 11/f- YSMIRA. COMM CID,
48-115 MAC;MD
5665 STURCzZOND:a YVE
LA QC.i.iNUA C,,A 92233
a'09YAIwESA CA. 91-626
CUh 4240
--"
USE OF PERMIT
RPM
24.2 S.F . ALU9rN1fp# I.ATVfCE P.ty,' PO 0XVEP, ('ICHO s#,' %
P RC°#ifiA1210 S:i°.
i�TMAI.11Z C '$' 01V 4�0X,1,FK47.!'f, ' Q
n P3,£ �
YL,Wffri VEX, &IMTKARY
Pl AX CHECK VISS MOM
CO3d:S'.1,pUcTi.0Wfeg,'C; 10 1 �,Ooa4l 0-00f) $ftS+.ftG
7
VJ 9 2002
FWANCE
9(M-. Ca'I"AL LON•i`I'..iSCI 109.A9.0 rlA's�'1 MAl7Z,.€�.
$ t'�c4 M
TOTAL FEURTMES VUE NOW
RECEIPT
DATEy
B,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
_
Final D Z_-
V(v
BLOCKWAI PROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
3 Tony M. Ybazre
Con=tr
566 Sturgcon Dr.
Costa Mesa, CA 92626-314, PLOT PLAN
NAME l /'U� Il ri / 1 i f—dI PHOT IG�i CL
C SrrUS ADDRESS (1 1 i Y if 7 �/I `- +E. I-/[— civ/ / 1-46, ',40,6
TRACT/PARCEL MAP LOT
ASSESSOR'S PARCEL NO.
0
REAR PROPERTY LINE
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tf CITY OF LA QUINTA
00 BUILDING & SAFETY DEPT.
-'APPROVED
FOR CONSTRUCTION
BY
DATE
-17KUN 1 YXUYJtK 1 T LJi4r-
r ,.
STREET
t g Vi 51` c too
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ARCHITECTURAL COMMITTEE CERTIFICATE
(Exhibit "A" to the Architectural
} Improvement Application and Agreement)
The Architectural Improvement Application and Ag Bement was
reviewed by the Architectural Committee on p: and has
been
Approved' Co�ditionally Approved Rejected
subj ect.I to the 'f ollowing
conditions set forth below
Returned for Further Information
Required'Modifications
. 1
Comments
Yes No
Recording to be sent by owner to County.IRecorder's
office for roof, and/or exterior wall modifications..
Deposit Required Deposit Amount'Required $
Dat Architectural.Committee
Architectural Committee Architectural Committee
Architectural Committee Architectural Commit,tee
DOTE: THIS APPROVAL IS VALID FOR 90 DAYS FROM APPROVAL DATE
t
i
Rev. 4-96 �l
1
i
F
_. EXHIBIT "1"
ARCHITECTURAL IMPROVEMENT APPLICATION AND AGREEMENT -
DATE
NAME (S) U (D C�l_c
(Print)
STREET ADDRESS
LOCAL PHONE UG'f-,T509�- OTHER PHONE .Sk+
REQUESTED IMPROVEMENT
Approval is requested for the above improvement according to
the plans attached.We have attached two (2) sets! of plans.
outlining the work to be done along'with a complete description
of the materials and colors to be used. If we are using a
contractor(s), we enclose copies of the. Contractor's License."
Attachments¢
(1) Two copies of ,the -Architectural Improvement
(2)
i
Application.
Two sets of plans with.materials and colors to be used.
Note: One set is -for- the management office; the other
set to be returned, to you as "Approved". k
(3) -Contract-pr's' name and copy of contractor's license. (Not.
required if" the' improvement is under $300..00 or if.
"Owner -Builder").
(4) Brochures (2) and/or color samples of manufactured products
to be used.
We have read the Architectural Committee Rules and Guidelines
and have furnished copies'. to all contractors tp be engaged by .
us and we agree to comply with those Rule's .add Guidelines.
We also understand tha.t it is our responsibility to insure that
our.Contractor(s) comply with said Rules. We acknowledge that
Building. Permits for home improvements may be required by the
City of.. La Quinta. .The cost of .permits, responsibility for
obtainirig:,them, and the su.bsequen,t inspections will be our
responsib'ilty,. ;•In all cases we 'recognize the requirement to
be .in compliance with 'applicable building codes including, but
not' limited to', those adopted subsequent to the original
completion and acceptance of our dwelling.
Rev. 4-96 e