9808-054 (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
If 59000 13 3/31/00
/ 1
yDate qr \ k t (r Signature of Contractor
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.
S`1'ATL F(I;V.D 129 7Ti I.."
(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, I shII forthwith comply with those-provision
.1 t1 flJ Applicant - , J" --1U1
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
thdabove-mentioned property for inspection purposes.
e Ita
Signature (Owner/Agent) -�L- . UVI Date !a i f i}
PERMIT#
BUILDING PERMIT
CONTROL#
DATEVALUATION �os�� ��� LOT TRACT
7.3 9 9-
uu^^• y^
/
JOB SITE
ADDRESS 54-636PW�RNM
APN 710-431-074
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ROBERT N JACOBS
CAL. TL CH 13UtIXER.9
54636 INV MNESS
52-7t 1. AVENIiAF1.V ELASCO
LA QUII`1'1"A. CA 92253
LA QIA _WCA
92253
(760)564-1309 C.13I:t#
40"
USE OF PERMIT
RESIDRN 1 AL t�XVr'itYN
HO 3.F. ATARI 7Rf1NCLOSURE
LUS•1 OTVI CONSTRUCTION 1101V :11,
I
ES IAII VE ED CGIN'T OF CONYff:11C rJON
s'so.00
iPl ate► IT ils'F e!, SUMtviA.itt'6,'`
Ki N C`IiECK FEE 191-000-439-318
COMSTRUCT ION FEE j 0 f -(.M-4 t 8-(= �YlIR.4i1
WCHAN1CAT. E 101.000421-000 g15.f3(1
'E :C 'MYCAL FFM ,10.1 -ow -420-000 6 tip.;5
S'1R( NGN-(0T10N fffX - X(-;S]D 101-000.241-000
t
>,z
I
r
•
i.
STUR-T*MAL CONSTRUMON AND PLAN ("Hr -,CK
$212,41
�
LESS RE.-.P� ID PEES
X(M
5711
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
/
Ducts '
Slab Grade
r
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
fel a�1
! '
Compressor
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
—L—
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
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
r
Final
Utility Notice (Perm)
rw
PGA WEST
RESIDENTIAL ASSOCIATION, INC.
July 15, 1998
Robert Jacobs
Dear Mr. Jacobs:
Your request for an architectural variance has been approved by Mr. Don Adolph, Architectural
Committee Chairperson. Specifically, you have the approval to proceed with the atrium enclosure
at your 54-636 Inverness residence. 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.
Sincerely,
C
Kel cGalliar
Operations Manager
cc: Architectural Committee
enclosure (1)
P.O. Box 1060, La Quinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125