9605-089 (ADD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
Z) co License # Lic. Class Exp. Date
0 r o,? I E 5o B 6110i'95%
LU
Z rr1__ Date4_ L Signature of Contractor ✓ ✓
Or
J Urn OWNER -BUILDER DECLARATI N
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
cY) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)CL z WORKER'S COMPENSATION DECLARATION
C Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �: compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD U U ( ) I have and will maintain workers' compensation insurance, as required by
Q Section 3700 of the Labor Code, for the performance of the work for which this
LO H permit is ^issue -My Alkers' compensation insurance carrier & policy no. are:
v Z mer Policy No.
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those, provisions.
Date�Tj Applicant -~� 7
V
Warning: Failure to secure Workers' Compen ation 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.
1 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) - / - Date -f
Y -- —
UILDING PERMIT PERMIT# CONTROL#
w�►.� Imy 3 3-4 4
DA - SI +G VALUATION S,34,t3",70 LOT TRACT
. ,
JOB SITE — r 56-341 8 Fl;'��i�iale�'..��!e1 XII
APN 7�1 .. �— ib
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CfIA1:1,ENE C E-1);*1PX,1.Er1'
Cot"JS"IMIJ " 10N
5314* Pi:RBLE x:;11
54705 AVE. CA1tEtANb%
LA 1„11 INTA. f'A 9225:3
LA QIJIMIA C.A. 92253
(708)8Ai 1837
riil?;s,5r;d-12,'7,1 ruo 2,*R
USE OF PERMIT
Al JOITION
1' r'1►�S[l.'1°' Iti�i�l4i ,`U7l �i'1'I��E�i
II -I 1'EMAT D COSM Or f.`ONSTk2ECI.i• ON
j41399.20
P0,RM1'1' F le CS f IAll, AlAR
Pt. ANt;tWCK Fits 1i?i-lx;0•�1,3�i 3ii3 5206.05
,XNt37'KLJCT10KFEE W-000-118-000 s3rAlii
N1601ANICiM, Fri 1"s 101 -000 -421 -Ow $1;.U3
iiLHl 71'itic'Al.1° -It 104.0W-4210-000 $tn68
;'1'sjXG NV)Td���7 VGE - ki,1311! 101-(11111-241.0110 $3.49
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S B-*P.l' AL C0NS"7°#JC11!_3N AND PLAN CIIECK
$SiZ s2
1..ENS P-RE.-4'AID I-TiM8
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'#'tYt`AL PIERNU 1' E'1~ N 01JE N08V
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RECEIPT
DATE- — --
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 Deck
Exhaust Fans
O.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
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
Final
Utility Notice (Perm)
ARCHITECTURAL/LANDSCAPE VARIANCE APPLICATION
PGA WEST RESIDENTIAL ASSOCIATION. INC.
h
Please complete and include this request form, along ..with
four (4)sets.of your proposed home improvement plans to:
PGA WEST RESIDENTIAL ASSOCIATION; INC.
P.O. Box 1060
La Quinta, CA 92253
or, 55-940 PGA Boulevard
La Quinta, CA 92253
Attn: Property Manager
NAME: L o V A) ,5 -1-1-y DATE: 5 1
ADDRESS: (o -,3�g 110g SLE 1��f}Ctf
PHONE: Z UNIT:
PROPOSED STARTING DATE: ne_
APPRO TE COMPL ION DATF:
Homeowner's Siqnature
The following appropriate information should accompany your
completed application:
1. Four (4) sets of complete plans�to include:
a. Improvements and/demolitions
b. Plot plan
c. All dimensions proposed
d. Relationship to neighboring units
e. Material and color scheme
f. Planned modifications of all external systems (landscape,
sprinklers, gas lines, electrical, etc.)
2. Agreement and Covenant Running with the. Land completed and
notarized. Two (2) original.
3. Conditions of Approval and Disclaimer form (signed)
4. Facing and Adjacent Neighbor form (if applicable).
5.- `"� Construction Regulations form (signed),r _ n
ELECTRICAL [ ] Approved [ ] Disapproved
f Signature Date
LANDSCAPE [ ] Approved [ ] Disapproved
Signature Date
ARCHITEC C I EE [,Approved [ ] Disapproved
Signature Date d 4
ARCH/Rev 8/95
11
1