0301-186 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affimm under penalty of perjury that I am licensed under provisions of
dapter 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 Exp. Date
245431 B W6 C4.2 1H 11,1130/V
Date `! " Signature of Contractor Ir
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.
1(�) 1 have and will maintain workers' compensation insurance, as required by
Sectien 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 STATE FUND Policy No. I SwIres
(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:). -n t - s Applicant—
Warning:
pplicant 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.
I
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:t6 `
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 with all 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.
Signature (Owner/Agent) Date
BUILDING `PERMIT PERMIT#
DATE VALUATION LOT TRACT
{ $97,394M LOT 163
JOB SITE
APN
ADDRESS 152,9&r, AV, ENWJ' ().RJZ + C`rOff
773-284-01 *7
OWNER
CONTRACTOR / DESIGNER / ENGINEER
.iAWW 13EL;nTAP
JAW_Z C. B�%. AP, JR.
RO, IM 297
'13.300 FIDDYA.+3rsICK I �
PAL.:. D .NEfflf CA 92261
PALM .l:)&WRT Cly. 92261
(760)777.9572 CZLO 2905
USE OF PERMIT
LOFRrE yA VM.�y .Ra.AD.4V
1646 S.F.SPI) PERMIT DOES NOT %� CIXDX BLDCK -WAIA, POOI, OR
DPJVZWAY APPROACH. Mo REDUCED PLAN CHECK Mil; FOR MULTT'1".9
PLA149 SAl1ff2 NOUS
TRACT CONSTRICTION 1,604.00 SF
PO.RCHIP.ATIO 117.00 SF
0A-.RAftrC'ARPORT 246.000 9I:
EI ASE'D 'r OF (:OXSTRUC OX
PERMIT FEE gUAWARY
CONSTRUCTION FEE 101-000-4184000 $630,50
PLAN CHECK FEE 101-000-{139-318 $131.24
FEE DEPOSIT 101-030-.39-31€1 425(00
Ib3I�,.0 HAN1r_kL FEE 181 _000-421 _000 $59.00
U&CTRICAL FLS 1014000.4.210-000 $113.9&
PL.UMBIN0 Fi:E 103-000.419-000 $124.00
9TRONO .MOT€ON FPff - RES.ID 101-000-241.01,00 391114
GR.,,P..DH40 FES 101-OtI"23-000 $15.00
1DZV91,0Px.12 IMPACT FL.F 82,4Wk. 00
PRECISE PLAN 101-M-441-345 $tic0:00
KOB-TOTAL MMSMUCTION A14D PL,.AN CMC:.
$3,569.04-
7..00 P"I.P;tA.o 1+>s7
4250,00
TOTAL i�af.�'IAl P.M'0" D@�C NOVY
FE
QDDEPT.
CITFI
RECEIPT
DATE
BY
I DZ FINALED �/
INSPECT R,A.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR ,
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
C)
Underground Ducts
Forms & Footings
Slab Grade
_ (. O
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
tp
F.A.U.
Framing
��
Compressor
Insulation
— d
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/ oz ,/
�02C/3 !CC
Final �p2�� . -_00_�i
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
_
�, Uj ��j
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
;Z �3 ��
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final -
Utility Notice (Gas) C./s
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:
.CERTIFICATE OF COMPLIANCE Jsc
DesertSands Unified SchoolADostlrict
47950 Dune'Palms•,RogadBERMUDA DUNESCn O
Date 2/21/03 La Quinti- SCA 92253 RAN IAN WE LS CJ
7 � INDIAN WELLS
No. 24163 .(760)'771.-8915 d�
PALM LQUINTA y
J�QINDIO y7�
0
Owner
James Belknap
APN #
773-284-017
Address
P.O. Box 297
Jurisdiction
La Quinta
City
Palm Desert Zip 92261
Permit#,
0301-186
Tract #
BLK 163
;'
Study Area
Type
Single Family Residence
No. of Units
1
Lot '# No. `Street - S.F.
Lot # :No.
Street S.F.
Unit 1 4
52585 Avenida Obregon 1604
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit
Unit 5
Unit 10
Comments Certs #24163 through 24167 used,for CC #305788
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 contain:fabiities 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 pursuanfto
Education Code Section 17620 and`Government Code 65995. Et Seq.
in the amount of $2.14 X 1,604 S.F. or $3,432.56 have ben "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/La Jolla Bank - James Belknap Check,No. 305788
Name on the:check Telephone 760-902-7444
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey $3,432:56 So.00
Payment Recd Over/Under
Signature G
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 installatio.ri emiit fdvthis-project is issued, or from the date on which
those amounts are paid to the Districts) 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
tl
Certificate of Occupancy
City of La u-in''a
Building and Safety.Department
W.
This Certificate issued pursuan#. to, the reggiremi? is -of Section 709; of the Uniform Bui/ding Code, .
certifying,. that, at the time of issuance; this struc"tcire was in comp/lance with the various ordinances
� e; ,,
of the City;regu/sting bui/ding'construCtion or use. ,For the. following::
BUILDING ADDRESS:` :52 5`85 AVENID�4<OBREGON'
.i'
Use Classification: SINGLE FAMILY DWELLING. Bldg ,.6. rmit No.: 4301-1.86 .
'Occupancy Group`: R-3 Type of Construction.: VN Land Use Zone:
Ownee of Building: JAMES BELKNAR,
Building Official
Address:
P.O. BOX 297.
City:
LA QUINTA, CA 92253
By:
KIRK'.KIRKLAND
Date:
JUNE 25, 2003
POST IN A CONSPICUOUS PLACE