0311-232 (SFD)LICENSED CONTRACTOR DECLARATION
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.
Professionals Code, and my License is in full force and effect. '
License # Lic. Class Ezp, Date
792225 B
Dae I Signature of Contractor
OWNER -BUILDER DECLARATION ter'
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 EXEMPT Policy No.
(This section need not be. completed if the permit valuation is for $100.00 or•less).
y) 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' 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 work for 180 days will subject permit to cancellatio
certify ify that I have read this application and state that the above information's
correct. I agree to comply with all City, and State laws relating to the buildilg
construction, and hereby authorize representatives of this City to enter up Iiul
the above-mentioned property for inspection purposes.
Signature (Owner/Agent), `�• Date L
t: w `w
BUILDING_ PERMIT PERMIT#
DATE' VALUATION LOT �� '' LOT TRACT
.i3s� s 13LX 2 TJ -
G.-{ -_ .1 ,3
JOB SITE'
APN
ADDRESS 52-07'.55 0,13RCE-GON
773-214-015
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LEONARD I-kM,
LE"t7ATARD L,A?tt9.
I I I� C: ZC7LE
I G'J:E C. _,E
g�1-7y;Ee:1.eSri,.t�,r�+C:T
t
ijJ>'�.11:1 iJ '0J.allS �..rdi 72260
73�I
y(,"'�..f'sy{:+�gy+7A + � S
PfiLbV1. LS-:�r.7.L.f. I CA 92,26.0
(760).440-9882 0-9882 ---141 6426
USE OF PERMIT
19.,04G.11 1V_ 1 11.13 .1�3<s >A3C1
i8?2Sf'' Sf¢i'.�ll>.Lr1£1MIT DOIFS PHOT 1VC"L1J0A B1=F: WAL,LSIVOC?.L QR SPA-
Cs.RIVEEVA,Y' APPRC?A0;'13PFRM.'T cO iNINPEC"" OW R.'F,c41, t,YiI3&D 8Y PUN -I(,'..`
WO)R.KS DEPT, 2001 CBC.
TRACT CC)NSTR'UCT1014 11812.00 O
0AJZAC,189ililiPO,RT 429.00 S
UINIMA".1921 COST T OF C C�J�•"�"��tt�c"T�:Ka�O
k.tblzf�4?Tri)
f7?J,? D POSIT 1101-000-439-3I9'' 4230100
MECH"ICAC.1x'3 K 1 t�1-QC1Q-•42'1-QOQ ' $56.50
I:LECT1t1CAL il�'�1? 101-000-420-000 $11,26. 5o
.
PLUMBIM0 VOY. 101-900-419-000
STIC4' M 1` O T KYN Ii U as - IMID 101 "0000''000 $14.21
Ok-ADINCI FEE 421-000
DEVEWPETt.:IMPACT tI*EE
Li,'.
T'T;31VSE PILKI�t 101 (# la -441--343 10a?.430
P1..,61:N CHECK FEF, 10A�000-4: 9-3I8. S43 LOO
CONSTRUCTION F'VZ 101-000-418-000 �ti61.f20
f1J&,7, 021x.1, CC3WSTRTJ�710N AeND PIA1 i CHECK K>
S3p932.8)
L,EM) PRE -PAID F,EEZ
42_2 ,W
AN 20 2004
RECEIPT
-w :,i, +:iC11
/ - -. /
BY
- �-•..
DATE FINALED
INSPECTOR
1-1
rt 1.-r nr-p,
j - /
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
v
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
06e IK—
Drywall - Int. Lath
$
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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 OG
Final
Utility Notice (Perm)
COMMENTS:
Building
Address
Owner 1-501VAKP ' /�
Mailing t' ., 1 !�
Address I,L �-
•
uCv -2- 2----
.. 3
P.O:;BOx 1504 APPLICATION ONLY
y 78-495 CALLE TAMPICO
LA, QUINTA, CALIFORNIA 92253 .
BUILDING: TYPE'CONST. OCC. GRP.
GfGL
• A P. Number
�) City Zip Tel:. R �/• f
CA.D % L'e aI Description �T rV L9- Loc ,<
Contactor 'Project *Description Nom+.-�F� 60AI511t C Ito
Address j•i� �LS�I�Gi'h � - ,r.+" . -, M.
City � `rp
Y�
Tel.
Zip ICA .4.419
�7
Tel.. �,`
(y
Zip
State
Lic: ff..
State ic.
A Classif.
d �
J 7i?/�
City
Lic: ti'
-
Sq. Ft. P/� i
No. No. Dw.
/
Estimated Valuation
y
✓
r Plan. Chk. Dep.
t„
.:Plan Chk. Bair.
Size :_• Ili 1 y.
Stories Units
+Arch., Engr.,'
Designer
r
S.M.I.•=
New ,G� Add O
Alter ❑ ' Repair ❑ Demolition ❑
Address
Tel.
r
'City
i
Zip
State
Lic: ff..
t •1 - `• BY: 1
t LICENSED CONTRACTOR'S DECLARATION-
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section'"'
70DO)'of Division 3 of the Business and Professions Code, and my license is in full force and'I
effect.
` • y
•• -
-
SIGNATURE -. DATE"-`
• OWNER -BUILDER DECLARATION. a'
I hereby 'affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Susiness and Professions Code:, Any city or county which requires.a., ,.
permit to construct, after., Improve, demolish, •, or repair'any structure, prior to its issuance also
requires the applicant for.such permit to file a signed statement that he is licensed pursuant to
the provisions of the -Contractor's License Law,_Chapfer 9 (commencing with Section{7000) of
Division 3 of the Business and Professions Code. or, that. he is exempt therefrom,. and, the basis'
for thealleged exemption. Any violation of Section -7031.5 by 'any 'applicant for, a permit ,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500). t -
L I, as owner of the property, or my employees with wages as their sole compensation, will i+
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and y •-
Professions Code: The `Contractor's License Law does not apply. -to an owner of property who
builds or improves thereon .and who does such.work himself or -through his •own, employees,,. r.
provided that such iinprovements.are not intended or offered for sale. If, however, the building
or improvement is sold within,one year of completion, the owner -builder will have the burden
of proving that he did not build or.improve for the purpose of sale.) i
Ifl 1, as owner of the property, am exclusivelycontracting with :licensed contractors to con -Plumbing
struct the project. (Sec.. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who,builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)'
If
i7 1 am exempt underSec. B. & P.C. for this reaso
Estimated Valuation
y
-
PERMIT r
r Plan. Chk. Dep.
t„
.:Plan Chk. Bair.
;+ Const. y "
-
Mach.
,Electrical
S.M.I.•=
Grading.
+ Driveway. Enc.,,
Date .0 y wner - -
Infrastructure
WORKERS' COMPENSATION DECLARATION,. ' r • -
hereby aflirm'that I have a ceilificate'of 'consen: to self -insure; or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 38,00, Labor Code.)
Policy No. Company I + '.
n Copy is filed with the city.. ❑'Certified copy is hereby furnished.'
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars ($100) valuation -,
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',
_
`
-
TOTAL '
REMARKS
P jee
- -
_
Lender's Name
Laws of Cali ornia.
NOTICE TO APPLICANT., r If. after making . this Certificate of Exemption "you should become
'ZONE; Ir
t •1 - `• BY: 1
subject to the 'Workers' Compensation , provisions ,of the Labor Code, you must forthwith
Minimum Setback
Distances:
. comply with, such provisions or this perm it shall be deemed'revoked.- r
front Setback fr
Rear Setback I
ea
f
CONSTRUCTION LENDING AGENCY r r
r
Side Street Setb
roe
t.
-
I hereby affirm that there is a construction lending agency the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) "
+
`Side Setback fro
P jee
Lender's Name
" `
•
Lender's Address
FINAL DATE
I
SJ
This is a building permit when properly filled out,,signed and validated, and is subject toexpiration if
thereunder is for 180 days. • �'
il
QUINTA
work suspended
.,,
?ISSUed
-.•
y'Date'
"
I certify that I have read this application and state that the above information is correct r
by: -
-REM
I agree to comply with all city.andcounty ordinances and state laws relatingto building
i
•'
;
�`
construction, and hereby, authorize representatives '-of,this city to enter the above-
•• �1-+
1
-
mentioned property lot inspection purposes. _, ..
Validated by:
Signature of adplicant Date
Mailing Address
Validation:
_•
°
'
�'
City, State, Zip
i'
#•
r
WHITE'-- FINANCE YELLOW = APPLICANT
PINK = BUILDING DIVISION
"-
CERTIFICATEOF COMPLIANCE
DesertxSanils`lDmfied School:+IDistrct . • 4� �o
470, Pne "Palma Rogad Q BERMUDA DUNES C"
Date 1/7/04 L'a' ,dinta, CA 92253 � RINDIAN WELLS
E 0
760 771=8515 PALM DESERT y
No. 25340 (760Y LA QUINTA
QINDIO
O
Owner
Leonard Lam
APN # .
773-214-015
Address
111 Chelsea Circle
Jurisdiction ,
La Quinta
City
Palm Desert Zip 92260
Permit #
0311-232
Tract #
BLK2 U-1
Study:Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street
Unit 1 4 52075 Obregon
Unit 2
Unit 3
Unit 4
Unit 5
Comments
S.F. Lot# No.
1812 Unit
Unit 7
Unit'8
Unit 9
Unit 10
Street S.F.
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under
500 square feet, detached accessory structures (spaces that do not oontairi facilities for Irving, sleeping, cooking, eating or. sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fee's 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 Governm®nt Code 65995; Et Seq.
in the amount of $2.14X 1;812 S.F. or $3;877.68 have. been paid for the property listed above and that
building permits and/or Certificates of Occupancy for thissquare`footage in this proposed project may now be issued.
Fees Paid By CC/Guaranty Bank - Leonard Lam . Check No. 2654174
Name.on the check Telephone 760/34.0-9882
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted- Sharon.McGilvrey Payment Recd go.00
$3,877.68 Over/Under
Signature
NOTICE: Pursuant to Government Code.S 68020(d)(1); thislorrve otify you thatthe;90- Iay,approvat,period in which you may protest the fees or
other payment identified -above will begin to run froiri.ihe,date,on i hick the build-i-ing';or,ihstaliition permit forthis.project is issued; or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on'the' Distria('s) behalf, whichever is earlier.
NOTICE:. This Document NOT. VALID if Duplicated
Embossed Original - Building Department/Applicant Copy -Applicant/Receipt Copy - Accounting
a .
a tirtu St$R
C tiny
Ot NnU
1itvt3c .0"
normcio aiQSc
A 3o3
1, t f'inP!
S Nrsu
NOU
sinu
sr flnu
lab^ : z^; S:iSblt t4it!tsbya'�t ,4tt,ti t>f1w�Mt Olf•1 ;+ittevaa attt:: tG3 P^.t�Gt>;p no a edi f2elfoo lon, es ob IYWaiG inad,c to inU ibnFP, hatat? wi, ,r tnj In4zetq wil to
soden± tmjm:totstGs. to (nxta,tnu la pnime ,9,1004,13 .Qr,js Ia rst .L trl ze:,ttioal m-On:ra tan Lb t4n3 tcosga) OnuhLA"s LV .Ct9$ .tsar atsupe OOZ
t0ef"im nniv:eXot OM 01-ub om:! ;! IS u' 3; pnrlsa mill 1gmcmx , et unto b-3mcn•oveAn eel ,GO., Son rt::s:ab g39sd tssrt 11 eemor;
3.18AOf.Ac'IA TOM ACIT9N13X3
o,. in5:1$1uq beavgrni agat g:iiicisl loorioa iseu cegiba,3 ztd i
.;30%2 !:
4
CITY'OF LA.QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS: 52-075 Ave. Obregon, La Quinta PERMIT NO: P91 OWNER: Leonard Lam BUILDER: Leonard Lam
This form shall be posted on the iob with the Building Inspection Card at all times in a conspicuous place Only persons appearing on this or list employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and / or the voidance
of building permit. For each applicable trade, all information request must be completed by applicant. "On File" is not acceptable.
lamMW_ Trade /Classification,Contractors
__�
State Contractors,�icense , _
' Workers,;Com _,ensation insurance ,
,Cif6=,us�ness
License
Company Name
Classification License No. Exp. Date'_.
„
Carrier Name . Policy Number Exp. Date
License No.
J:Exp. Date`'
rz
(e.g. A,B,C-8) (XXXXX)- (xx/xx/xx)
(Format Varies) _ (xx/)x/xx) (XX/XX/XX)
(xx/)x%xx)
(XX%XX/XX)
EARTHWORK x""11? '
Rud 's Masonry Concrete
C8
782663
8/13/04
STATE FUNDS boas oolooso
1/1(05
6346
1/28/04
FF MING (C 5 sHM_ERNANbEZCONSTRUCT1
B
735136
4/36/05
VIRGINIA SURETY CO IN 005000li629
1/1/04
2377
1/31/04
STR,UCTI„STEEL,' C51F
�iE
M.4S®N,_RgY�G 29. �a, ` ” Rud 's Mason Concrete
C8
782663
8/13/04
STATE FUNDS'D46-,o0ooso;
1/1%05
6346
1/28/04
PLUMBING (G36 a• - 'Valley Plumbing
C36
273088..
4/30/05
CLARENDON NAT"ONS C 02K,R0027214'
10/25/04
LATH,, PLASTER 4G35
_�.. -Rud 's Mason Concrete
C8
782663
8/13/04
STATE FUNDS oas oolooso_
..
1/1/05
6346
1/28/04
DR1N1/AL C9__ [•"ZA,M -
B
792225•
3/31/05:
-
EXEMPT.f N/A
N/A
�i yZ 6T
9^oY
FiUAC PENNY . La Quinta.Air-conditioning
C20
749342
5/31/04
STATE .FUNDS „oas ool2sss.,
1/1/04
5951
1/31/04
ELECTRIC�11. 10; �_
J M Electric
C10
631350=
10/31/05
} EXEMPT N/A
N/A "
2907-
12/1/04_"
R,®OFING C39:
ROOF TILE SPECIALTY;INC,;.;
C39
810537
7/31/04
Employer Occident." oimb 06300
2/20/04
1420
11/24/04
SHEETME-,TANIC-3-401)",
FL®y®RINLG C1:�
Jim Spencer Floor Coveiing
C15
591598
3/31/04
STATE FUNDS 0689177-01
3/31/04
1578
-9/6/04
.
,GING° X 17
,rVIACKLjNMIRRORa.cLAssirvc,;,,.-
_ .. -. _ .,
C17
. -, 704161
4/30/05,
STATE FUNDS- ��22s-0ozast7_
`1/1/05
INSUI &TI,ON EC 2<
Para.
Paragon Insulation-
C20
632072
9/30/05
TRAVELERS PROP TC2TUB122
06/31/04
3291
8/25/04
SEVVAGE Da1SP ,C42
Valley Plumbing
C36
273088 1
4/30/05
CLARENDON NAT'L INS C 02KR002T214(
10/25/04
/O
PAINTING 3,033;
L Ch --Owner—
B
792225
3/31/03
EXEMPT N/A
N/A
CER%�MIC 1ILE C
awn'er
B
792225
3/31/03
EXEMPT N/A
N/A
6
L S-
,C�BINEtTS G,�6 „
Cabinet Art
C5
787248
11/30/04
STATE FUNDS 046 60124051
10/27/04
3005
10/4/04
3
FEN�CjNG 013 x
Rud 's Masonry Concrete
C8
782663
8/13/04
STATE FUNDS 046-0000_96
1/1/05
6346
1/28/04
DSCAA
11�N APING C 2,7
Z Id— OWner
B
792225
3/31/03
EXEMPT N/A
N/A
6 Y26
7- %• os-
J & L Material
c-61 d03
472187
8/31/05
STATE FUNDS s32-000bt37 .
11/1/04
794
5/8/04
dr
il
7K—
:0K
4/
e—
1W
a
r
Schedule A (Form 990 or 990 -EZ) 2001 PALM SPRINGS -ACADEMY OF MEDICINE 23-7081147 Page 6
Part:Vll I Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations (See instructions) ,
51 Did the reporting organization directly or indirectly engage in any of the following with any other organization described in section 501(c)
of the Code (other than'section 501(c)(3) organizations) or in section 527, relating to political organizations?
a Transfers from the reporting organization to a noncharitable exempt organization of: Yes No
(i)Cash.................................................................................................... 51a (i) X
(ii)Other assets.............................................................................................. a (ii) X
b Other transactions:
(i)Sales or exchanges of assets with a noncharitable exempt organization ....................................... b (i) X
(ii)Purchases of assets from a noncharitable exempt organization ............................................... b (ii) X
(iii)Rental of facilities, equipment, or other assets............................................................... b (iii) X
(iv)Reimbursement arrangements.............................................................................. b (iv) X
(v)Loans or loan guarantees.................................................................................. b(v) X
(vi)Performance of services or membership or fundraising solicitations ........................................... b(vi) X
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees ..................................... c X
d If the answer to any of the above is 'Yes,' complete the, following. schedule. Column (b) should always show the fair market value of
the goods, other assets, or services given by the reportingorganization. If the organization receivecl less than fair market value in
any transaction or sharing arrangement, show in column d) the value of the goods, other assets, or services received:
(a) (b) (c) (d)
Line no. Amount involved Name of noncharitable exempt organization Description of transfers, transactions, and sharing arrangements
N/A
52a Is the organization directly or indirect) affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? ........................... Yes M No
BAA TEEA04061- 09/25/01 Schedule A (Form 990 or 990 -EZ) 2001