9908-924 (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 Division 3 of the Business and
L Professionals Code, and my License is in full force and effect.
a`C License # Lic. Class Exp. Date
?'P_W�
Zr--
Date Signature of Contractor
O
JU OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
F—
License Law for the following reason:
Z( ) 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).
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
Q Date Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
Z I hereby affirm under penalty of perjury one of the following declarations:
U) FQ- Q () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
0_J _J performance of the work for which this permit is issued.
m U U () I have and will maintain workers' compensation insurance, as required by
p Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
V Z Cartier Policy No.
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�a
g (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' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
t 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
s: 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, indemnif,,
j; & hold harmless the City of La Quinta, its officers, agents and employee:
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
L permit, or cessation of work for 180 days will subject permit to cancellatior
I certify that I have read this application and state that the above information 1
• correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
Y `BUILDING PERMIT PERMrT9908-"u
DATE VALUATION $11.2%.O LOT TRACT
JOB SITE
ADDRESS 11P750 AVENWA OBRONI APN
FG774-155-001
OWNER CONTRACTOR / DESIGNER / ENGINEER
WILLIAM Ci MWER OWNER / BUILDER
53750 AVENIDA OBREGON
LA QUINTA ' CA 92253
USE OF PERMIT
RESIDENTIAL ADDMON
208 SY. ROOM ADDITION. INMTIOATION FEE ASSESSED PER 1997
UNWORM ADMINISTRATIVE CODE M.5 FOR WORK BEGUN WITHOUT
BUR DING PER IIT.
ADDITION
208.00 SF
ESTIMATED COST Of CONSTRUCITON
PERMIT FEE SUMMARY
PLAN CHECK FEE
101-000439-318
587.75
CONSTRUCTIONFEB
101-000-418-000
$135.00
FLECTRICAL.FEE
101-000-420-000
115.75
STRONG MOTION FEE - RESED
1014000-2414)00
$1.13
GRADING FEE
101-000-423-000
$20.00
INVESTIGATION FEE
1014000-423-000
$135.00
Q1 M_gVW A 1 CONSTRUCnON AND PLAN CHECK
LESS PRE -PAID FEES
TOTAL PERMIT FEES DUE NOW
BY I DATE FINALED
CBL#
INSPECTOR
$394.63
$0.00
$394.63
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City' of, La Quinta
X.
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—
Building& Safety Division 4
P.O.' BOX 1504
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P I # ....
-78-495 Calle Tampico,
La Quinta, ' 92
CA: M
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Building Permit Application and Tracking Sheet
Project Address;
V,
Owner's Name:,/
A. P. Number: 7
Address:- -7<0
Legal Description: 4-,-/ 4��,
22�L /)IJ-? ov
Ciry,ST, Zip:: L'A UM Nd1A I�Ij a Y-3
Contractor:
Telephone: _r, .1
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Project Description:
City.ST,Zip:
Telephone:
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State Lic. 4
City Lic. #:
&24117A idX15111116 �CkAl
Arch.. Emir- Designer:
Address:
City. ST. Zip:
-.12eAo�
Telephone:
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Construction Type: Occupancy:
State Lic. 9*:
.6
P roject type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.: loe
#Stories:
# Unit . s:
Telephoner of Contact Person:
Estimated Value of Project:
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I, William G. Turner, owner of property located at 53750 Avenida
Obregon, La Quinta, CA 92253, authorize Chris Rubadou, as my agent in charge
to oversee and remodel of my house at the above address.
Date, 2
William G. Turner, Owner
Phone: 760-564-6097
Alt. 760-202-0204
C_1
Notice:
Document Cannot Be Duplicated
Date 8/6/99
No. 19153
Owner NameWilliam G. Turner
No, 53-750
City La Quinta
Tract #
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN # 774-155-001
Jurisdiction La Quinta
Permit #
Street Avenida Obregon . Log #
Zip 92253 Study Area
Lot # Square Footage 208
Type of Development Residential Addition No. of Units 1
Comments
sq. ft. room addition to existing singe tdnifly residence.
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 or replacement 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 Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the,amount of
0.00 X 208 or $ 0.00"T :io,,P,',
the property listed above and that Duildiing 1) -
permits and/or Certificates of Occupancy for this square footage in this proposed project may,,now be issued3'�`
:
Fees Paid By N/A - Chris Rubadou
Telephone 3224�697
Name on the check "��, N r- r•
Ttnpn*l� I y
By Dr. Doris Wilson
Superintendent'�`"'�"
Fee collected /exempted by Juanita Green Exempt $0.00
Check No. N/A
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) 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 sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting