0212-137 (MISC)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/
f 1..
Date " Signature of __....actor �f1 '
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 STATE F�I31fT., Policy No. 46R794
(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 thvsefprovIsjpn`s.
Date: ' • Applicant
Warning: Failure to secure Workers' Compensat}on 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.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT t'h.°1 TRACT
JOB SITE
APN
ADDRESS IC:,Ii�.Q1{, . 4 WING.9D TI'CKY1'
OWNER
CONTRACTOR/DESIGNER/EN INEER
P,GA WFSTRESIDENTIAT..BV-1%,
F.Y'ix:'.E7:i."�I.1':;i:t>?Jf^`i"Icii'(,:'�vG`.
PALM D11.'45'E °f CA 92211
21AN 1.iIT+C,A n-0 l 13
USE OF PERMIT
BI.f. 0, 4: 55.421, 55- 1' `, =..i . RX.P:&JR. HANI)PAI1.S' &TX�'CK
�'c�.�3'I ENQ
VAIXAT'.dON 'I'500m, 1"",
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P141RAWK fiUMVIARY
CIONISTRUCTION, FFIF 101-000-4.18-.00 $311,U�J
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RECEIPT DATE
BY -' -'"` DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
Final
Set Backs
Footings
Bond Beam
Waste Lines
Water Piping
Plumbinp ToF
Shower Pars
Sewer Lateral
Sewer Corine
Gas Piping
Gas Test
BLOCKWALL APPROVALS
PLUMBING APPROVALS
f _
Final
Utility Notice (Gas)
ELECTRICAL APPROVJZ. ,S
Temp. Power Pale
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.H.
Smoke Detectors
Temo. Use of Power
OPERATION
DATE
INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
F i F, a i
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Neater Final _
Plumbing Finn.
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Fi. T
CCMPA-ENTS:
POOLS - SPAS
Final
Utility Notice (Perm)
7w
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M E M O
Send to: EPOCH CONSTRUCTION
Address:
Attention: HARRY
Regarding: PGA WEST 2 - MEDALIST DECK REPAIRS
From: Tim Golba
Date. 1128/03
Copies To: File
Comments:
Harry,
Please let this memorandum confirm that our office has inspected all
4 buildings of deck repairs for the current MEDALIST phase of repairs
for PGA West 2 Residential Association. This includes all of the upper
level entry and rear balcony deck repairs for the buildings along
Winged,Foot, Southern Hills and Laurel Valley. We find the repairs to be
in conformance with the manufacturer's specification and are
approved by our office.
Please let me know if we can offer any further clarification for you or
the City of La Quinta in this matter.
Sincerely,
Tim Golba, Principal
GOLBA ARCHITECTURE
G O L B A A R C H I T E C T U R E
656 NINTH AVFNUE SAN DIEGO CA 92101 VOICE: 619.231.9905 FAX: 619.231.4288