9606-139 (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
Date fj4 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
Sectidh 3700 of the Labor Code, for the performance of the work for which this
permit is;Isued Myjjworkers' compensation insurance carrieri&;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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions:
Date: f.,, Applicant
r t•.
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 property for inspection purposes:
- � fry � ;
Signature (Owner/Agent) y . � i +�j - ••-{t J)1•Pi Date_ -71 C7 -+'L
� �__
DATE
BUILDING PERMIT
612A19(; VALUATION $14,11101,69 LOT
PERMIT # CONTROL #
WOW 111.39 3576
TRACT
JOB SITE ADDRESS 54-7121NW 4NM% APN 'i .431-0"
OWNER CONTRACTOR/DESIGNER/ENGINEER
MICHAEL S u. DIANA. ftA1N1iS CA€,'€~�+ 113U1ta€A.IkS
51722 INVERNESS WAY 527.1€ V1:LASCO
LA QUINTA, CA 92253 LA QUlNTA CA �r,,5:3
(61 ft;64-.1309 0111.0 4tY2
USE OF PERMIT
11:1431,' IVIRIUNI FsNC LOSIM.
SU`8; .M. , CONST€?yUC1ION :AND €' ,AN CEMCK
_ USS PtUM)A.t.D FEES $0.00
1 \ 11 \ �t t;A:: PERMIT VERS i)iTl:;ltii $212. 5
JAN 2�•.199� •
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_� DA BY DATE FINALED INSPECTOR
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s
EST INI, D CONS,
PEMM1111'i' €+'KE,'[ItVtj1'iA1tV
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$17'e(�1.21A►
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Nif.�� e3#iNX.Aft 1-116
101,-000.421-000
$15.00
1�1'Ai( l'k.1CAl..s"k R
101-000—VO-000
X18,(01
3 Tt'7t'3O'N1CRION FEE, - KV'5110
t.0 l -4.1"M-000
S.4 f
SU`8; .M. , CONST€?yUC1ION :AND €' ,AN CEMCK
_ USS PtUM)A.t.D FEES $0.00
1 \ 11 \ �t t;A:: PERMIT VERS i)iTl:;ltii $212. 5
JAN 2�•.199� •
,y
_� DA BY DATE FINALED INSPECTOR
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air +i
Steel
Combustion Air
Roof Deck f
Exhaust Fans
0.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
Drywall - Int. Lath
Final
Final ON Zg
BLOCKWALnAR__OVAL_S
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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)
n
PGA WEST
flESIDENTIAL ASSOCIATION, INC.
June 19, 1996
Mr. and Mrs. Raines
54-722 Inverness Way
La.Quinfa, Ca. 92253
Dear Mr. and Mrs. Raines,
Architectural approval is hereby given on your requested atrium enclosure. Our architectural
requirements specify submittal of "4" sets of plans. 2 we keep and 2 stamped sets are to be
returned to you. As we only received 2 sets, we cannot return any to you for submittal to
building department.
Please be advised that with this construction the Homeowners Association is no longer
responsible for roof leaks in this area of the house, nor are we responsible for any drainage back-
up from reworked roof or atrium drains.
Your help in contractors compliance to our construction requirements would be much
appreciated.
Sincerely,
Don Adolph
Chairperson, Architectural Committee
PGA West Residential Association, Inc.
P.O. Box 1060, La Quinta, California 92253, Telephone 619-771-1234 FAX 619-771-5125
COACHELLA VALLEY UNIFIED SCHOOL DISTRICT
CERTIFICATE OF COMPLIANCE
(Government Code 53080)
"Project Name:
Project Address: 54-722 Inverness Way, La Quinta, Ca 92274
Project Owner's Name: Michael & Diana Raines Phone No.:
Project Description: Room Addition
Building Type (Check one): Residential XX (Incle No. of Dwellings)
Tract No.: Lot No.:
(If tract, attach Schedule "A" of all lots by tract, square footage for each lot and total.)
Assessor's Parcel No.: 769-431-090
(If Schedule "A" is used show Assessor's Parcel No. for each lot if one exists or Assessor's Parcel No. for parcels before subdivided.)
Total square feet of Building Area: 104 Sq. Ft,.
Certification of Applicant/Owners. The person signing certifies that the above information is correct and makes
this statement under penalty of perjury and further represents that he/she is authorized to sign on behalf of the
owner/developer.
Dated: �ZS/ qlA Signature:
City/County Certification:
(Signature) Optional
(Title)
SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE
SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE ONE):
Gov. Code Gov. Code Project Agreement Existingec o e
53080/65995 65970 Approval prior to 1/1/87 requirement.
Note: Pursuant to AB -181,
room additions or enclosure of 500 Sgkt.
or less, are exempt from developer fee
Total Number of Sq./Ft. 1014
Amount per Sq/Ft. $ -0
Amount Collected $ -0
School District Official : Title: Asst. Suaerintendent, Administrative Serv.
Foch "Tut" Pens'
Phone: (619) 399-5137. Ext. 235
Note: AB 2926 and SB 201 fees are capped at $1.84 per square foot for all residential construction, and at $0.30
per square foot for commercial/industrial projects.