9809-131 (AR)j
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
668379
Date 17�r.-r'�/` Signature of Contractor r
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.
w` i'} a u t'ill� f}ili�:S?uw t
S
(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.
C6de, I shall forthwith comply with those provisions.
t Date`e-_'�Applicant s r`
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;1
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 resujt 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 cornply.with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
thwabove-mentioned property for inspection purposes.
%Signature (Owner/Agent) r---%�Ty Dateik
's
BUILDINGPERMIT PERMIT# CONTROL#
.9809-131 A pp�� 55
DATE 9/2211)8 VALUATION S39,+. 8 ,60 LOT. TRACT -,/
JOB SITE
ADDRESS
APN '66.. ,.
OWNER a. ;€^
CONTRACTOR / DESIGNER / ENGINEER
X. HAWLEY JACKSON!
c}muS w vo i n t TI' d
55099INVE NE4SS
V0 BOA. 1005
1,it 1N'1A c:: k, 92253
PALM SPRINGS CA Qiol
(�fit1)32 :Si)2`3 011.9
USE OF PERMIT
RRSUAIv"MLADDa'1�l� N
:KITC104 i FfV1OL i' ROOM MANSION, ADDING Z6 SR LIVIN
AREA, 144 NY. ('0V.ILLIU-i:1 PNrIO NAdSG:. tl`rvL' RIOA ltSMK 001
z
CUSTOM CONS':i'ste.7+:.i. ON ?36.00 S1
PORC.41TIA110 144.W S17
f
1?'�iL'.is�s�'I'1f;�N 1y,7(lfa.(sOI.S
.
EYFTN.WfED COSH;; Or, CIONS RUCi>;OW
39,919.60
rmur ver, SUMMARY .
PLAN CHECK FEET
(l//ll�d-�O(C1��/3��1ftp� @@�`�!.!
�.rl,lNST: UMMON NEVE 1011-'✓tf`)418-000 5340.50
.
WIC ILIVOCAL FV. 101.-000.421.000 $!S.Ctt1
ELEC—MCA1r FEF, 101-600-420-010 S23.a2
t3'1 ROW, MOTION -. R SRAI 10.1-000-241.400 �l.Utf
C3'R!Z'C M_ FER 101-000-423-M
G�
SOU.�P `�'� ' ID, )NS''%�:11JM., ON ANY) R'LAN O'HECK
IS A {9.A
LESS PREMIAMFEES
$0.00
SEP 2 3.1998
`1 OTAL PERM1 T FE1siS W iTE NOW
ti39.5
-ITY OF
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
it
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _ �Y
l� Z I
Underground Ducts
Ducts
Slab Grade
✓ A
Return Air„
Steel
Combustion Air
Roof Deck
_ _
/
Exhaust Fans
O.K to Wrap _
/�
F.A.U.
Framing
Z `
Compressor
Vents
Insulation N
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
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
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:
��lJ
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)
01
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 399-5137, Ext. 235
Project Name:
Owner's Name:
Project Address:_
Project Description:
APN
Type of
Residential
This Box For District Use On]
DEVELOPER FEES PAID
AREA:
AMOUNT: RCPT N:
CK. M CASH:
INITIALS DATE:
CERTIFICATE OF COMPLIANCE
(Government code 53080)
Tract
Commercial
Date: September 21, 1998
Phone No.
Lot #'s:
Industrial
'---Total-Square Feet of Building Area: 936 SQ-Ft-
Certification
n_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 athe owner/developer.
Dated' q
_ `��� Signature:
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT :Ha� EN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Gov. Code
53080/65995
Number of Sq.Ft.
Amount per Sq.Ft.
Amount Collected
Gov. Code Project
65970 Approval
236
$ —0
$ -n
Agreement Existing Not Subject to Fee
Prior to 1/1/87 Requirement
Note: Pursuant to AB -181 any room
additions/enclosures of 500 sq. ft.
or less are exempt from developer fees
By: Foch "Tut" Pensis. Assistant Superintendent Administrative Services
Administrator in Charge
t4
Certificate issued by: Marcela Valdez Signature:
Facilities Clerk
NOTE: AB 2926 and SB 201 fees are capped at $1.93 per square foot for all residential construction, and at $0.31 per square foot
for commercial/industrial projects.
Sep -12-98 10:19A
ti
PGA WEST
RESIDENTIAL ASSOCIATION, INC.
PGA WEST RESIDENTIAL ASSOCIATION, INC. '
Notice of Architectural Approval
This shall serve as written notification to the City of La Quinta that Mr. Hawley Jackson of 55-499
Inverness has gained written approval -from the PGA West Residential Association, Inc.
Architectural Committee and from a Management Employee of the Homeowner Association.
Specifically, Mr. Jackson has the approval to proceed with the addition of 300 square feet to the
kitchen area of his unit. This signed approval must precede the issuance of permits from the City
of La Quinta.
IIfq
�E
Date
9- -4
Date
P.O. Box 1060, La Cluinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125
P.02
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