9607-128 (AR)LICENSED CONTRACTOR DECLARATION . :
I hereby, affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of. ivision 3 of the' Business and
Professionals Code, and my License is in full fore and effect.
License # Lic. Class Exp. Date
>a
�iSi4 t -1.t? i! i198
Date _ t- 6 kgriature 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 (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 3779—Lhe:1Laal gLLGode, for the performance of ihWworklVoltr�w�hi�ch.this
permit. is Issued. My workers' compensation insurance carrier &.policy.no. are:
Carrier. Policy No.
(This section need not be completed if
certify that in the performance c
I shall :not. employ any person in any
workers' compensation laws of Calif
subject to the workers' compensation
Code ha fo i h comply with tli
Date: Applicant
✓•permit valuation is for $100.00 or less).
Oe work for which this permit is issued,
anner, so as to become subject to the
ia, and agree that if I should become
OvWons of Section 3700 of the Labor
Warning: Failure to 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
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 wgrk for 180 days will subject permit to cancellation.
I certify that I haveread tis pplication and state that the above information is
correct. I agree to comp ith all City, and State laws relating to the building
construction, and hereb thorize representatives of this City to enter upon
the above-mentioned pr p rty for inspection` purposes.
Signature (Owner/Agen � ` Date {
��
BUILDING PERMIT PERMT# C°NTRDL�
9�,07_1x8 �. � � 3803
DATE „' VALUATION �fii.�43•1��1 LOT TRACT
.:r;'
JOB SITEkk 681Z1i:Gi' N
APN '634-38041116
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1C1d4f1ICb PO -11.11"D ICKS
A&N-1 tuON9111Lr- ION
44975 ,AYWfl).A. U�i� '00N,
lis -0'70 CALLS C..l' M
i,.A QU1N1'A CA' 92253
LA QUINTA. C'A. x2253
ft1c1lSfi 0la0
(619)564-4837, Ctil.# 626
USE OF PERMIT
It�)11A Alll)i•i'1�;:r'N �W. �'d,l�nl.?E,l> .
I
i+S°1'D:YATED C`C)S" i- 0V C®1g'XntBJt"rt0N
Pli! RIMI f' MARY
PLA94 3•iP.CK F11174 101-000.439-318 ` WAS
CONSTRLfC I SIN FEE -000418 -ow ss!,00
.101
N1lsC%4A141CAL FEE 513.00
ELEC I'i21CA.f, M -101-000-420-000 $17.52
Kt MRiNG F`IyF 1,01-000-419-006 $22,50
MNC11?40t EON FFE,- RESID . 101 X00-241-000 5.96
o.
SUB-T(YrAl. CONSTRUC"T(ON AND PLAN C ECK
$189.23
LESS PRE -PAID HES
$0.00
TA ,RM1 i' FI CIS MAE, ! .MV
S189123.
AUG Oz.
1996
By,
RECEIPT
DATE
DATE FINALED
INSPECTOR
INSPECTION RECORD r +
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
0 rap
F.A.U.
ramin
Compressor
Insulation
yd
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
eTzoowl
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
/
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:
"ter//
Building
Address
Owner
P, i G4,
,� q�
Mailing
Address
( op
City
L
f I�/'
V I, /" f p�
zip 22� 7
Contraofor.c
fn A
el.
P.O. BOX IW14 APPLICATION ONLY
78-105 CALLE ESTADO
LA OUINTA, CALIFORNIA12253
Cl— ]BUILDING: TYPE CONST. OCC. GRP.
n
State Lic. u Glty
& Classif. " [ $7 59 Lic. x
A.P. Number
Legal Description D �,
Project Description
Sq. Ft. —7/ C- No. No. Dw.
Add
1 efgr. yk w•—I[ _&- 1 New ❑
City ZipState
� ® q 7 � 0 Lic:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
'OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractoes License law for the following.
reason: (Sec. 7031.5.Busi ass and Professions Lode:. My city or county uaNd requires .a
permit to construct, aaer. improve. demoi'sh, orrepair any ' -structure. Prior, to es Issuance .also
requires the applicant for such permit to fib a tpnad stfemant that be! Is licensed pursuant to
Me provisions of the Contractor's. License Law,CAapfor 9 feormrnelrp a1M,section 7000) of
Division 3 of the Business and Professions Coda, or thatM Is axampt therefrom, and Ma basis
'or the alleged exemption. Any violation of Section 7031:3 by any applicant for a pants
subjects rhe applicant to a civil Penalty of not more Mari five nundn0 daYn (11500). -
: I, as owner of the properly, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for safe. (Sec. 7044. Buisness_and
Professions Code: The Contractor's License Law does not appy to an owner of property who.
builds or improves fhereon and who does -such work himself or throughftown employees.
Provided that such awrovements are not intended or offered for sale. e, however. Me building
or rrnprovemenr is sold within one year of completion.. the owner-buider will have the burden
of provmg that he Cod not build or improve for the purpose of sale.)
' 1, as owner of the properly, am exclusively contracting with licensW:contractors to con-
struct the project. (Sec 70aa, Business andL Professions Code: rhe Contractor's license Law
does not apply to on owner of properly who builds Or improves thereon, and wlo contracts fof
such protects with a contractor(s)'licensed pursuant to the Contractor's License Law.)
I am exempt under Sec. S. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a ceinlficate-of consent to self -insure, -or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3600. Labor Cods.)
Policy No. Company
Copy is filed with the city. E Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be Compered i the Permit is for one hundred doors (11100) valuation
or less I
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.
Date Owner
NOTICE To APPLICANT m, cher making this Certificate of Exempfgn you Should become
Subject 1
0 the workers' Compensation provisions of Me Labor Cads. you must forthwith
comply wen such prOv4rOrls Of tis Permit shoji be deemed revoked. .
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. ?Sac. 3097, Civil Code.)
Lenders Name "
Lender's Address
This is abuilding permit when'propernd y filled out, signed and validated, ais subject to
expiration if work thereunder is suspended for 190 days.
1 certify that I nave read this application and state that the above information Is eorraet.
I agree to comply with all city and county ordinances and state Ism relating to building
construction, and hereby authorize representatives -o1 this city 'to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
i
Alter ❑ Repair ❑
Demolition E
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
Estimated Valuation 0
t
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
i
Const.
•
Mech.
•DO
Electrical
17, S -Y.
Plumbing
'tZ • SO
S.M.I.
,
Grading
Driveway Enc.
Inf rastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
I
Desert Sands Unified.School District
Notice: 82 879 Highway 111
Indio, CA; 92201
Duplicated
Cannot Be Dupli�ated 619=775.-3.500
...E
CERTIFI'CATE OF COMPLIANCE
Date 8/1/96 "_ APN # 631-380-016
No. 14777 Jurisdiction ' La Quinta
Owner Name chard R. Fredericks Permit #
No. 49875 Street Avenida Obregon Log #
City La Quints Zip . 92253 Study Area 121.
Tract # Lot:# Square Footage, 72
Type of Development Residential ,Addition No. of Units, 1
Comments
At the present time the Desert Sands Unified. School Districtdoes not collect fees on' garages/carports,
covered patios/walkways,'iesidential`addi ions under 500. quare feet,,detached accessory structures or
replacernent' mobilehomes It'`has` been determined the above-named owner 'is exempt from paying
school fees at this time -due'-to the following reason:
RESIDENTIAL ADDITION 500 SQ. FT. OR LESS
-EXEMPT
This- certifies that school'facility:fees imposed pursuant to :Government .Code 53080
in the amount of 0,00 X 72 or $ 0.00
the property listed aboveand that building permits and/or Certificates of Occupancy for
this square footage in.thisproposed project may now be issue&
Fees Paid By n/a Telephone- 564-4832
Name on the check'
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson . ,Exempt $0.00
- Check.No. n/a
Signature h {�x . '� ►
Collector: Attach a copy of county or city plan checkapplication form to district copy for all waivers.
Embossed Original- Building Dept%Applicant Copy = Applicant/Receipt, Copy Accounting
Remodel
and
add
a closet.
At the present time the Desert Sands Unified. School Districtdoes not collect fees on' garages/carports,
covered patios/walkways,'iesidential`addi ions under 500. quare feet,,detached accessory structures or
replacernent' mobilehomes It'`has` been determined the above-named owner 'is exempt from paying
school fees at this time -due'-to the following reason:
RESIDENTIAL ADDITION 500 SQ. FT. OR LESS
-EXEMPT
This- certifies that school'facility:fees imposed pursuant to :Government .Code 53080
in the amount of 0,00 X 72 or $ 0.00
the property listed aboveand that building permits and/or Certificates of Occupancy for
this square footage in.thisproposed project may now be issue&
Fees Paid By n/a Telephone- 564-4832
Name on the check'
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson . ,Exempt $0.00
- Check.No. n/a
Signature h {�x . '� ►
Collector: Attach a copy of county or city plan checkapplication form to district copy for all waivers.
Embossed Original- Building Dept%Applicant Copy = Applicant/Receipt, Copy Accounting