9902-028 (AR)�j LICENSED CONTRACTOR DECLARATION
'(I. he Eby affirm under penalty of perjury that I am licensed under provisions of
`7 Ghaoier 9,;,(comWAcing 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
� I n
Date ' Signature of Contractor _
�i
'OWNER -BUILDER DECLARATION
f 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to.construct the project (Sec. 7044, Business & Professionals
Code)'.
O 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.
t.( )..I have andiwill 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' corn ensation insurance carrier & policy no. are:
Carrier Policy No.
(This section eed 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 1phould become
subject to the workers' compensationrprovision'rs of Section 370.0 of the Labor
Code, I sh Il forthwith comply with thdUprovilions/ p/
1;1 Applicant �'� IA"A �---/t- , 6�� /r
Jr� v—, I ; Vy ..
Warning: Failure Jto secure Workers' Compensation 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
fora 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 pursuaAto
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 withall 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,
i
Sig ture (Owner/Agent) A Datez _ 't
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 9902-028 TRACT
52.713.20
JOB SITE
ADDRESS
APN
55-692 OAK T.ICC .,
769-351-006
OWNER
CONTRACTOR / DESIGNER / ENGINEER - -
't OOSUNG KWAK
SOUrN WEST CONCEPTS
55692 OAK TREE
82723 DR. CARREON BLVD.
LA QUTNT:i CA 97253
INDIO CA 92201.
(760)342-5555 CBL# 1461
USE OF PERMIT
SOUT14 WEST CONCEPTS
ADDITION OF35SQ,FT.2SKYL1Ci1rlS.KITaEN'tR MODE-
SUPPIZWNTAtf ADDITION OP 42SQYT. TO 10ASTGR SUITE
' CUSTOM CONVERSION 42.0 S}'
ESTIMATED COST OV CONSTRUCTION
2,713.2-11
PERMIT FEE SiJ1kINiARY
PLAN C'f1F3M", FEZ 1014=439,318 V5. til
CONSTRUCTION FF.E 141-000418-000. $54.00
ELECTRICAL FEF 101-000420-= $16,47
STRONG i110TION FEE - CC MNI 100.000-241-•(1'00 $.57
r, AL• CONI," UCTIO1d AND PLAt�l CHECK
$106.14
LESS PRE -PAID r 1iS
$Tuu) i
#L P A IFF FEES DUE NOW
$106.14
ccJ
Nf V.� i
RECEIPT
RECEIPT
T�T
DATE k
BY r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs A
Underground Ducts
Forms & Footings
Ducts
f lab 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 3
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
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)
COMMENTS:
0
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 399-5137, Ext. 235
nk Rnr Fnr niefrirs T Tco rlmk,
DEVELOPER FEES PAID
AREA:
AMOUNT: - RCPT ft:
CK. #: CASH:
WITIALS: DATE:
CERTIFICATE OF COMPLIANCE
(Government code 53080)
Project Name: Date: February 5, 1999
Owner's Name: Y'obsungAwak Phone No. 342-5555
Project Addrecc, 55-692 Oak Tree PGA hest La Qui nta CA 92253
769 351 006
Type
Commercial
Area: , 42 Sq. Ft.
Lot '#'s:
Industrial
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 autho ' ed to Jign on behalf of the owner/developer.
Dated: �s_. 39 Signature: V --,A
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Gov. Code Gov. Code Project Agreement Existing Not Subject to Fee
53080/65995 65970 Approval Prior to 1/1/87 Requirement
Note: Pursuant to AB -181, any room
Number of Sq.Ft: 42 ,
Amount per Sq.Ft. $ -0 are exempt from developer fees .
Amount Collected $ -0
By: Foch "Tut" Pensis. Assistant Superintendent Administrative Services
Administrator in Charge '
Certificate issued by: Marce 1 a Valdez Signature:
Facilities Clerk'
n� r ria: canon Douro or roe wvernmem coot emam as nac®nry ori tua r, as loon as t. 549, !i=Wt of the 5Q t of C4hform; 19%effective Jan. 1, 199J, rcgnim War mu uhool dimity provides a artivto mote m the prof rhe
time of paymar of ¢hoot fees, mid(pcon paymeor or other esaWona. This notice is to advin Too duo spy protest m regal to =hamoums or the vaMty thamf m actordarce amh Section 660!6 of the Govv®rm Code and other app' k I�
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.