0304-151 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisionso
Chapter 9 (commencing with Section 7000) of Division 3 of the Business aPa,
Professionals Code, and my License is in full force and effect./
License # Lic. Class Exp. Date
628444
Date %' Signature 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 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 07947E MAID Policy No. 134D04-02
(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 those provisions. -
Date: ! Applicant—_
Warning: Failure to secure Workers' Co pensation 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 em eS-
2. Any permit issued as a result of this application becomes null an �C�ppld if
work is not commenced within 180 days from date of issuance fJst cc�i
permit, or cessation of work for 180 days will subject permit to can Ta on.
I certify that I have read this application and state that the above infor �ti n is
correct. I agree to comply with all City, and State laws relating to the buil ing
construction, and hereby authorize representatives of this City to a er uport
the above-mentioned property for inspection purposes.
'Signature (Owner/Agent) _ Date «= J
PERMIT#
BUILDING PERMIT d�3
DATE % VALUATION ; ;*, �a LOT6.. TRACT jkjL 220 U-2
JOB SITE
ADDRESS 51- TID AX8 ,P1 M 0W1, 'X)N APN 77X IM -002
OWNER
7.9 17 O.AFA 1Y.T.
PAL.Ni UMMT CA .922,60
USE OF PERMIT
DRIV WAY A PP13c.A011
TRACT CONSTRUC71ON-
PORCHIPATIO
C1&RAt':SFMAARPORT
CONTRACTOR/DESIGNER/EN (NEER
SINE rv0A , I(.X Elisa CA MEMR's" 04DIfIST
73-170t�i�Q:t3X"
1.�n.tm r
1140.00 sit,
41,09 3•F'
EVITIVWM C"•OAiY OF, i"O.1t'ii4MMMI ON
FX'MTFLT. AMM iIc V
C0NvIffN.UCT!C i,1 ;E
1.01.000•418-000
HUM
PI—W- CHECK P71B:
101_01WA39-31�1`1
8511X96
FEE OF010SIIT
101-000-439-31F
42SIDA
M1XbANIC AL PZE
101-000-42 i -Qty::
$59,08
RIM"" 5v1CA.I,€leE
101 -000,420-000
Vto, 69
PLUMBPt4a FU
101
$11110
STROM 1s3.^^-: IUM FEE - RUSID
101 -WO -241 -00""
$10M
GRAIDY,N0 iii?
101-000.42:3-O".•`=
$13.01?
DW LOPM IMPA. T YET
32;409.60
PREC;SE P1. 1.1i
101-L100-441--3,1,_;'
$100.00
5TJF '.rCy'TAL CON'acrfRIX 171>9 Al -'•!:t 3'I.,AK C;iF.i X
TOTS ' t 4 T►1�'1 )T :_r3; ,1aWf HCl
N 16 2003 I,
I:RECEIP_Ti,J: T?_�__ID � E BY _ 11 F D / INSP 0R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
tet Backs
—p 3
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
IV
Combustion Air
Roof Deck
- , 0 3 7
Exhaust Fans
O.K. to Wrap
_ / —p
F.A.U.
Framing
-a 3
Compressor
Insulation
Vents
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
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) ev
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 0-0 VIK
Final _
Utility Notice (Perm)
CERTIFICATE OF COMPLIANCE JFK,
Desert Sands Unified School District
47950 Dune Palms Road
Q BERMUDA DUNES r
R
Date 6/16/03 La Quinta, CA 92253 RANCHO MIRAGE d
' INDIAN WELLS 1
No. 24545 (760) 771-8515 �cyi PALM LA QUINTA ���
m
Owner
Pine Mountain Real Estate Inc
APN #
773-124-011
Address
73170 Amber St
Jurisdiction
La Quinta
City
Palm Desert Zip 92260
Permit #
0304-151
Tract #
BLK 20 U-2
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street S.F.
Lot # No.
Street S.F.
Unit 1 6
51720 Avenida Obregon 1527
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the above=named owner is exempt from paying school fees at this time due to the following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,527 1 S.F. or $3,267.78 have been paid for the property listed above and that
building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued.
Fees Paid By CC/Union Bank of California - Doug Peters Check No. 8370651
Name on the check Telephone 760/771.8409
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Shapq $3,267.78 So.00
'O'l If, - Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this Will serve to notify you that the 90 -day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this'project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting