0207-159 (COMB)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
57711117 104 176
Date 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 (beC. /U44, BUSIlle5S & PIUfeSSIUIIdIS CULle).
( ) 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 AYF, FUIND Policy No. 044-01-001%9?
(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 otSection 3700 of the Labor
Code, I shall forthwith comply with those provisions.Ai
Date:* +; Applicant x!..,,"r, 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, i
addition to the cost of compensation, damages as provided for in Section 370@ i
of the Labor Code, interest and attorney's fees. I
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on hi
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:
!,
Signature (Owner/Agent) %� % f-' Datej r'7'1Z_
BUILDING PERMIT PEROT# ►
DATE VALUATION LOT 02011- M TRACT
JOB SITE
ADDRESS 361FRORY.Y. YINAM
APN
- r
OWNER
CONTRACTOR / DESIGNER / ENGINEER
33Mon RHCDES
S ARXVt+tNM'R'UCAON'CO.
5S -36Z TWEB Y BEACH
39725
I.A Qilii► TA CA 92253
PA.i.a!"v1MW CA 92211
o,760.)345-9711 awj790
USt OF FtHMI I
51A SP A],."i3MAWC?C1O PATIC3.. 5 LF 4' BLOCK W14,1[ UCITY STA"HDA1', I
OUTDOOR FIREPLrA,C&
VALiTATION 41 8.00 LS
4 alai.'. W .A.LL ,00 LF
PORrxIPAINO M-0.11 SF
NEWITMA'1ED COST OF C';ON TR47MON
12.009A9
PKR.?,rflT,FrK1L SUMIARY
PLAN CHMI1 FE -11 101.000,439.318 $93.60
f °t" NS la?g3.1CTION FEE 1.01-000-419.000 P "�.0o
SIRON53MOTION -.RESIP 101.000-241.0.00 SII.2b
i
/A
( , ti ). ttii'L
CITY Or LAQUINTA
FINANCEDEPT
IAMBS TIE PAMM
$0100
TOSAyCTE( d'.S:aLa:l DVII, mo
RECEIPT
DATE �7
/. .�� arc✓
BY
1 e7It
DATE OALAD
INSPE R
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 Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing lilQ 0
Compressor
Insulation
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
POOLS - SPAS
BLOCKWALL APPROVAL
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
Neater 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)
SENT BY:—P6A"WE'ST'`RESIDENTIAL,ASSOC, I;
p/� �
TY
PGA WEST
RESIDENTIAL ASSOCIATION, INC.
November 15, 2002
g� PB Realty investment
Jesse Rhodes
55-362 Pebble Beach
La Quinta, CA 92253
Dear Mr. Rhodes:
p-
760 771 5125; NOV-15-02 4:20PM;
u
PAGE' 2/2
Mr. Don Adolph Architectural Committee Chairman, has approved your request to install a trellis
French doors, and an outdoor fireplace at your 55-362 Pebble Beach residence. Any ele::trical wiring
exposed during construction must be reported to the Homeowners' Association immedfiately. 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 ii matches the
original request. An approval is based only on the aesthetics of your proposed plan and should not
6e taken as any certification as to the construction worthiness or structural integrity of -die proposed
change.
We appreciate your cooperation in submitting this request for approval. If I may be of fiarthe
assistance, please contact me at the HOA office, (760) 771-1234 extension 15.
Sincerely,
Kelly cGalliard
Operations Manager
cc: Arcbitectural Committee
.enclosure
P.O. Box 1080, La Quinta, Califomia 92253, Telephone 764-771-1234 FAX 780771-5125