0212-145 (RER)u�-tIv�EU (:UN'1'HAL t UH UtCLAHAI IUN
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
cv .W Professionals Code, and my Ucense;is in full force and effect.
C n m License # y Lic. Class Exp. Date
W ^ 774382 Tit C33 WC ,; ��' =912(
ZO�ySignature of Contractor
J U OWNER -BUILDER DECLARATION
d^ 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).'
( ) I am exempt under Section , B&P.C. for this reason
N
Date Signature of Owner
O ,
(L aQ WORKER'S COMPENSATION DECLARATION
CCI hereby affirm under penalty of perjury one of the following declarations:
H 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
ca—i Q performance of the work for which this permit is issued.
Q L) , �r) I have and will maintain workers' compensation insurance, as required by
0U' Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 permit Is issued. My workers' compensation insurance carrier & policy no. are:
I _ Carrier STATS FUND Policy No. 460'84
0°.v
g (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 9f Section 3700 of the Labor
3. 'de, I shall forthwith comply with thos9 provisiofis....
Date: J , Applicant '
Warning: Failure to secure Workers' Compensatiorf-Coverage is unlawful and
tei
shall subject an employer tominal 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 iff�
work Is not commenced within 180 days from date of Issuance of such
t 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. 1 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)2a �' ^ !_ Date, r ;
BUILDING PERMIT �tHMl17!-1�i.S
DATE VALUATION LOT . TRACT
IOC E4'J��00
JOB SITE
APN
ADDRESS J%Do, 12 LAUIM VALT.S'Y'
.
OWNER
CONTRACTOR/DESIGNER/EN INEER
PGAUTW R1'S;; MMAL HOA
M)OM CONMRNCnON, 114C.
42.600 CAROUNE COURT
7062 CONVOY COURT
PALM DF1TRT CA 92211
SAN DI GO CA 92111
(858)560.0698
USE OF PERMIT
C3i.AI, x1T.71ZbINC.1:
BLDO. 13: 55-400,55412,53434. REPAIR. HANDRAILS & DrCK
COATiNO
VALMATJON 4,300,00 Lel
MIMAIXD COST OF MRSWuC'T.1.ON
a,�0v.00
PIMMIT F9r
CONSTRUCTION ME 101.000-418.000 $30.00
-' JIB-** C IMRUMON AND PLAN CfW,=
`
T- 30.00
✓' �.I: IX33 PRR-FAM FE3• 3
$0.00
'ALPERMIT FROES DUE MW
$30.00
RECEIPTs
DATE 7
BY F, .
DATE FINALED
INSPECTOR
Send to: EPOCH CONSTRUCTION
Address:
Attention: HARRY
Regarding: PGA WEST 2 - MEDALIST DECK REPAIRS
From: Tim Golba
Date: 1 /28/03
Copies To: File
Comments:
Harry,
Please let this memorandum confirm that our office has inspected all
14 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 manufacturers 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
Ll
G O L B A A R C H I T E C T U R E
656 NINTH AVENUE SAN DIEGO CA' 92101 VOICE: 619.231.9905 FAX: 619.231.4.288