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9706-123 (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-61 4W09 ate.10 11 Signature Signature of Contractor s 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. VI 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. .a MIT, (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 to the workerscompensation provisions of Section 3700 of the -Labor ode, I shall forthwith comply with those provisions. Date: �d A forthwith /AK s?� Warning: Failure to secure Workers` C pensationlcoverage 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 txcorrect. I agree to comply with all City, and State laws relating to the building constrction, and hereby authorize representatives of this City to enter upon t above-mentioned property for inspection purposes_ . `rSignature-(Owner/Agent)--,— 1� DateZ�f ' BUILDING PERMIT PERMIT# �. CONTROL# 97(O>F► I.; 5388 DATE VALUATION LOT TRACT 6120197 $2,713.00' JOB SITE�y ADDRESS 48-1.17 VIS'.I A CIIrLO APN 646-I�nnt� 049 OWNER CONTRACTOR/DESIGNER/ENGINEER ftoUl"W S. � INHI EIRR0 M L .MRS TONY NC Y"RAR11A. CONSt'. CO. 'V1,MA CIELO 566 S'I'iIEBt i C4TJ DIUVE LA. QLT.N'rA. CA 92253 c 091A. MESA CA, 9267 (714)97M-493 Mir, 440 USE OF PERMIT 4lti &.'F, AfAb-fi_Ii1M S. ALT'':1CR PAY10 COVET, (stoic, 45o3s-1 FIS IAI,aTED C.' TI' OF CONS'g UICTI0.' N - 2,79100 ��ci�i�a{��.Fa.ot.�� A:OIA!vd/•i�t.��•�;('Bt+� 1'f,l•f`f airia`'K I'cm 101-000-43.9-318 .fr"4#443.14, t14�..;�IKt_�ltRKQ00$540)t'9W33"1014 t; FI3 - 101-NW241-00o der?9 0 CL Z Stlj,3ZIrt Al.r�0Nk,`TX0C'Tta:N ANO MAN ppc77:�'a��iEei��.��-,k ,60 `4'OTAJ. PERMIT ,F4+ OS TWE N'OW RECEIPT DATE BY DATE FINALED INSPECTOR %*V... .14ft M 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 OX to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL A PROVALS 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 Udlfty 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: (Print STREET ADDRESS. LOCAL PHONE a7 -Y -Y, • OTHER PHONE. REQUESTED IMPROVEMENTS `=z: /> Approval is requested'!ior- the- above improvement according to t-heplans 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 Application.. (2) Two sets of plans with.materials and. --colors to be used. Note:. One'. set is, for the management office; the. other sett to be returned to you,2,as "Approved" ' (3) Contractor's' name and copy of,'contractor's- license. (Not required if the imp.ro,vement. 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 to be 'engaged by us and" we agree to comply- with those Rules, and Guidelines. We also understand that it is 'our responsibility to insure that our Contractors) comply -with said Rules. ' We acknowledge -that Building .Permits 'for home , improvements may be requilred by the City of La Quinta. - The. cost ''of permits, responsibility. for obtaining :them, and the subsequent inspections will be our responsibility. In all cases we recognize the requirement to be in compliance with applicable building -codes including, but not limited to, those adopted 'subsequent -tp. the original -completion and acceptance of our dwelling. 1 Rev. 4-96 r . Page Two The Association_ has no responsibility whatever iq AChieving compliance. with newer building codes which apply as a -result of. Homeownerprompted •modifications, Further,- we understand that approval will not be granted for any modification which directly or indirectly, conflicts with .the Declarations of Covenants, Conditions. and. Restrictions. "We also understand we are responsible for the accurate -,determination of property lines and setbacks (as applicable). - We also understand that ',we will, be 'responsible for all costs of this improvement and',for costs, associated with any repair to common, area occurring as a result' of implementing, this improvement. Examples include, but -are not limited'to, sprinkler and irrigation systems, buildings, roofs,,.'exterior walls, lawns, -plants and drainage. Further we recognize that any modifications to the common area irrigation and landscaping scheme, are subject to formal acceptance by the Association. Any required remedy to achieve the required maintenance standard or irrigation standard are our responsibility. Additionally,. we understand that the job site must be,' left reasonably clean at the end .of each day, that no debris .nor dirt may be dumped in common area or=left at job site. Any maintenance or,'replacement of permitted improvements, except for certain landscaping, which are beyond "initial" improvements, shall 'be the homeo.wner's responsibility. We agree to indemnify for ourselves, 'as well as --'for our successors and . assigns;. and covenant and agree to hold Association' harmless -.from all claims,' demands or liability arising out of or encountered .in connection with this Agreement, whether such claims, demands or liability are caused by Owners, Owners' agents -or employees',', or contractors or subcontractors employed on' the project,, their agents` or employees, or caused by any, products installed .on the project by said contractor(s) or subcontractor(s). Such'indemnification,sha'll extend to claims, demands or liability for personal injuries and/or property damage occurring during installation, as well as after completion,. including, but not :limited to, all Owners' maintenance responsibilities provided herein. We. further .indemnify and hold the Association harmless from a.11 liability related to. -.any damage to existing improvements .(wherever located, within the Subdivision) resulting from the installation/construction>of the Architectural Improvement If required by the' Architectural Review Committee, we agree to record:,' and pay fo.r the recording, of: this improvement at the County. Recorder's office. We further acknowledge ,,that, the Architectural Committee may require a deposit be submitted before work is begun. l Rev. 4-96 Page Three We further- agree that this improvement will be completed in a reasonable and diligent manner. "We further agree that. 1) if we*do not correct any damage caused as a result of implementation of this improvement or, 2) if we fail to complete this improvement within the allowed time . frame the Homeowners Association may elect to complete the work andtor repairs, and we will be responsible for the actual costs of such work. Payment to the Association is authorized by us in the form of an assessment or monthly penalty payments as approved in the Guidelines. j By signing this Agreement below, we agree. to be bound by its terms and conditions and any conditions set forth by the Architectural Committee in the Architectural Committee Certificate, which is attached. hereto as Exhibit "A" and. made a part hereof by this reference. Signat of Owners: (Signature.) (Signal ure) Rev. 4-96 ARCHITECTURAL COMMITTEE CERTIFICATE (Exhibit "A" to the Architectural Improvement Application and Agreement) ' The Architectural Improvement.'Application and Agreement was reviewed by the Architecturall Committee. on and has been: Approved 4�onditiona'lly, Approved Rejected subject to, the following conditions.s.et forth below .Returned for Further Information Required Modifications Comments Yes No -; < Rrding`to `be sent by owner to .County Recorder's office for .roof and/or exterior wall modifications: E/Deposit Required' Deposit Amount'Required $ ,/Ar"a 1'7 D e ? Architectural Committee Arc itecCu. r ommittee,, Architectural Committee Architectural Committee Architectural Committee NOTE: THIS APPROVAL IS VALID FOR 90. DAYS FROM APPROVAL DATE Rev. 4-96 l NAME 6u1�0 � SITUS ADDRBss ll V1574C'l` o �� CM r pal Piz) -� Dry LOT i REAR PROPERTYLb- — S S J J. D D E E P. — p � �17 BUILDING F'�, P R - Y p �:� P^- V ACCEPTE- FO 5 Y L SUBJECT TO INSTA iiN AS PJ E2 L .LP�l R a F D RLL RPPUCABLE C IDES FROiv'F' PROPERTYLINE k//5r,4 C/E/o STREET .284-263 REV 4190