0009-072 (RER)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
�� 7 08 B 0813112,(
Date 00Signature of Contractor ""'+�" "—N
J
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.
( L),' 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 EXEMPT 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, Lshall,fo'rt ith comply with'thoke proviyjons.
.,Date: �f J �� Applicant—
Warning:
pplicant
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.
I
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 applicator 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 property for inspecti n purposes.. f
Signature (Owner/Agent) +'` 1`^� `�` ` DateS
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
09aw(i $40j=.(*
JOB SITE
APN
ADDRESS.
OWNER
CONTRACTOR/DESIGNER/EN (NEER
IN&M monill;
C101VT9Mi7=0N DF.SagG syn11'7 s INC,
54.377 UMRNESS
P. 0, BOX 628
LA, Qi71 TTA CA 82253
LA QLrWTA CA X2253
(760)771.3593 CDL* 5830
USE OF PERMIT
OWMAJ- t.]7IrTi
AXPLA.CE EXISTINC9.f10ORS AT (2) LIVINq M.8DRU, (3) 0.BDKM
rdd11 TI 8068 JIM. DOOR & REPLAM FAIST NO WINDOWSAT (2) RAT HS,
DININq KITCHEN. MINIMUM .73 U•V'ALUE FOR ALL FENESTRATION,
VALUATION 41000169 LS
�.uu'Un" ` D COS"1 O%°" C01VI7Ck2UCI-f%C3n
40y0A0OO
BOOM= 10M SUAWARV
PLAN CHECK FEE 101-000.435-528 $227,18
CONSTRUCTION ME 101-000-419-000 3349.56
ZLECTI' CAL FEP 101-000420-000 SAW
STRONG MOTION FER €i.ESID 101-000-241-000 X4.00
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SUB -TCYIAL CO}TI-RUC`.CION, AK0 PIA2�t CIOICK
'0600.68
IMS �r. -PAV-.)1:�'i
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`l1MEFEms f FEES :SUE NOW
RECEIPT
DATE tom'
r
BY ,
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 DeckExhaust
Fans
O.K. to Wrap r 1. 17
F.A.U.
Framing a4wlmCompressor
Insulation /
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
-
Exterior Lath
Drywall - Int. Lath
Final
Final I wtzz
"POOLS - SPAS
BLOCKWALL APPROVAIIS
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
COMMENTS:
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)
Sep 05 00 01:-26p PGR WEST Res. I
PGA WEST
RESIDENTIAL ASSOCIATION, INC.
August 29, 2000
M. Cathy Morris
Dear Ms. Morris:
(7601771-•5125
Pool f i
Fox NototeJ
To 1 L
nrtex
771
P. t
Your request for an architectural variance has been approved by Mr. Ralph Anderson, Architectural
Committee Member. Specifically, you have the approval to proceed with the remodel at your 54=37,,7,
Inverness`residence as depicted on the approved plans. Upon completion, please submit the enclosed
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
original request. An approval is based only on the aesthetics of your proposed plan 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 extension 15.
Sincerel
Ke McGalliard
Operations Manager
cc: Architectural Committee
enclosure (1)
Ct P.O. Box 1060, La Quinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125