9709-059 (AR)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
ate J )�/� Signature of Contract r^ -
OWNER -BUILDER DECLARAION
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
S c ion 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.
(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
ubject to the workers' compensation provisions of Section 3 00 of the Labor
Code, I shall forthwith comply with those $rovisions.
Date:Applicant o' d . n it
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. autho rize representatives of this City to enter upon
/the above-mentioned property f� Inspection purppooseess.
/Signature (Owner/Agent)1�T ! Date\
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BUILDING PERMIT PERMI {fie. ts�fi� CONT!5R 9O O
DATE VALUATION :5^7 1 <). 3fs LOT TRACT �+ v
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JOB Sn't �.
ADDRESS .�� — 1. ID i}.rad� N�fin
APN 769-4451.4317
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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RECEIPT
DATE
ay
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel X
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 4446-.
Drywall - Int. Lath
Final
Final — (� -
BLOCKWALL APPROVALS
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:
Srric (G= tgLAaMS v?aATe� flp-::10
zaL STA lL &k 4 —t b -4 8 .g ,
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 399-5137, Ext. 235
•Phis lius Ful- District lase 0111N.
CERTIFICATE OF COMPLIANCE
(Government Code 53080)
Project Name: Date: September 15, 1997_
Owner's Name: John & Bonnie Lee Dervivanis phone No.
Address: 54-332 Inverness, La Quinta, CA 92253
Project Description: Room Addition
AP1V c 769 451 017 Tract #:
Type of Development: Residential XX
Commercial
Lot #:
Industrial
Total Square Feet of Building Area: 497 Sq. Ft.
Certification of Applicant/Owners: The person signing certifies that the above iii
under penalty of perjury and further represents that hc/shc is autorhized to sign 9ir-belialf-
Dated: c? • • 0-r-7
Signature:
n,�on is corrcei mid makes this si,Itcmcllt
"o
***********************9e****yr*******9e 7t*******************Yk yr Yr*7't******K:✓;x**�lxKYr*rtyc •Y.kic �:X�t**is Y; •r,^:
SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE 13 E1 N OR W 11.1. B- -E
SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCI-E ON V I:
Gov. Code Gov. Code Project
53080/65995 65970 Approval
Number of Sq./Ft. 497
Amount per Sq/Ft. $ -0
Amount Collected S -n
Agreement Existing Not subject to 1'ee
prior to 1/1/87 requirement.
Note: Pursuant to AB -181 any room additions
or enclosures of 500 Sq.Ft. or less, are
exempt from developer fees.
By: Foch "Tut" Pensis, Assistant Superintendent Administrative Services
Administrator in Charge
nn �2
Certificate issued by: Marcella;' Valdez Signature: ' -
Facilities Department
NLNICE: Section 66020 of the vovenurtent Code enacted as Assembly Bill 30RI, set foNt as Chapter 540- Statutes of Ute State of Ctaliforida, 1996 effective Jars. 1, 007.:cglnres th::t iiia scllooi distnel provide a wr3tca rp h
Lie project apphcalll at die Wile o: payllit Ill of scl tool ICe>, illit1plioll 1: yin -m Ur othef rxaetioiu. Iles Atlee LS to advisc yoli dial aril' pl'Ulesl'JI fgard to �udh :.1._s ::. . •.:.:!::Lr..::..::>: u, .a: a,:.:..:e :•::::.. .......: . .
of die Uovenutielit lode and od:ci apphcablc Iaw, cU11tlnCllces wadi soca: payllicilt UI pcl'!,�inraltcc of ally odlcr icquucment as deicrihed ur S;cuon oo020 t,i'dic
protest dlereof nimst occur widdii 90 calendar days dleraailei.
Note: AB 2926 and SB 201 fees are capped at $1.84 per square foot for all residential constniction. a!id at S0. ;0
per square foot for conunerciallindustrial projects.
Dev. Fees Disk: Misc\Cert-Com.Sttm. (REV. 1/97)
PGA WEST
RESIDENTIAL ASSOCIATION, INC.
August 21, 1997
John Derdivanis
54-332 Inverness
La Quinta, Ca. 92253
Dear Mr. Derdivanis:
Your request for an architectural variance has been approved by Mr. Dan Shepardson, Architectural
Committee Member. Specifically, you have the approval to proceed with the room addition at your
54-332 Inverness residence. Upon completion of the room addition, please submit the Notice of
Completion form to this office.
We reserve the right to make a final inspection of this change to make sure that it matches the
or request. An approval is based only on the aesthetics of your proposed change and should
not be taken as any certification as to the construction worthiness or structural integrity of the
proposed change.
We appreciate your cooperation in submitting this request for approval., If I may be of further
assistance, please contact me at the HOA office, (760) 771=1234.
Sincerely,
Kel y cGalliard
Operations Manager
cc: Architectural Committee
Terry Smith .
P.O. Box 1060, La Quinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125