9709-031 (AR). LICENSED -CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I a licensed under provisions of
Chapter, n-jeornmencing with Section 7000) 1 ivision 3 of the Business and
Professionals Code, and my License is in full orce and effect.
License # Lic. CI s Exp. Date
Date Signature of Contract r
OWNER-BUILDEF,f 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 Iurider 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 Policy No.
0,C)LDEN2r'1,r%LE I0_12
(This section need not be completed /,manner
ermit valuation is for $100.00 or less).
() I certify that in the performance work for which.this permit is issued,
I shall not employ any person in an so as to become subject to the
w •• rkers' compensation laws of Ca�, and agree that if I should become
Eject to the workers' compens fI provisions of+Section 3700 of the Labor
(Code,;) 16 it comply wit ch e rr_0V1sions.
Date:`` [[ !!tr %% Applicant
Warning: Failure to secure WdFkers' 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.
T.'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 cert 'ify that I have read this application and state that the above information is
correct. I agree to comply wity,611 City, and State laws relating to the building
construction, and hereby au rize represekatives of this City to enter upon
tJ�,e above-mentioned properiVfor ipspection purpose
Signature (Owner/Agent) Date
s
PERMIT # CONTROL #
BUILDING PERMIT 0704-0.34 5667;
DATE VALUATION LOT TRACT ,
JOB SITE APN
ADDRESS-�+ri t���i� iaS1 C� R! t'..i)i� 773-051-027 t.
OWNER CONTRACTOR/DESIGNER/ENGINEER '
LA U Y f' PI',;1C! rl'I'A.
930O.A.RAPA.H(Y CSL) M0
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USE OF PERMIT
A 1)DN
7" 70 CALLE CA(AZ
('0 W 1 ! 7 L.t1 t jl IIN7'A (.'A 4225:
f -13R3'? C"Ts1:9 t►26
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RECEIPT DATE BY DATE FINALED INSPECTOR
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$111.66
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$9448
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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 4&ttay ALVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall 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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out bf H I V
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas '
e,Gas Test
—ApUffces
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPR VALS
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)
Desert Sands United School Distriet
Notice: .82-87 Highway hll
Document Cannot Be Duplicated Indo;`CA 92201
619-7754500
CERTIFICATE-OPCOMPLIANCE
Date 9/11/97 APN # 773-051-027
No. 16071 Jurisdiction. La Quinta
Owner Name Larry F. Plscioita -Permit #
No. 51251 Street: Avenida Obregon Log #
City La Quinta zip; .',92253 Study Area
Tract # Lot # Square,Footage 152.1
'Type of Development Residential Addition No. of Units 1
Comments
At the present time, the Desert Sarids Unified School.; District does not, collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square -feet ,46.tached accessorystivctures or, replacement mobilehomes.
It has been determined the above -mined owner. is exempt "from paying school fees. at this.tiime due to the following
reason:
EXEMPTION NOT APPLICABLE
This certifies that school, facility fees imposed.pursuant to Government.Code53080 in the amount of
1.84 X 1,521 or $ 2;798:64 :th4ropertylisted above.and'that building
permits and/or Certificates of Occupancy for this square footage in this proposed project miay i>ow'6e issued
Fees Paid By cc/First Community Bank/AM Builders ,
^TelepFone` 564-4832
Name on -the check -
By Dr. Doris Wilson `
Superintendent
Fee collected /exempted by Pauline Pearsori Payment Received 798.64
Check No. 074064
Signature
VOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you thatihe 90 -day approval;period in which you,may protest the fees or other payment iderit�ed
above will begin to run from the dale on which the building or installation permit for lhisprojedis'sssued or on whichdfiey are paid to the Districts) or to another public entity authorized to
;ollect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check -'application form to diitrict copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting