9703-014 (AR)'-LICENSED CONTRACTOR DECLARATION'
I hereby affirm under penalty of perjury that I am licensed underprovisions of
-Chapter 9 (commencing with Section 7000) of. Division 3 of the,Business and
Prdfes-sionals'Code, and my License is in full force anis effect. -
License # ; - Lia Class .n . - Exp. Date
Date' Signature of Contractor
y y t
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the.Contractor's-
. License Law for the following reason:
(
1,, as owner of t66- property, or my employees with wages as thelrsol
compensation, will do the work, and the structure is not intended or offered fqr
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 - 1 - `Y�? ' Signature of Owner�'i:,,16�:, "..�
WORKER'S COMPENSATION'DETLARATfON
I hereby affirm under penalty of perjury one of the' following declarations:
".O 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 liy
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. `
(This section need not be completed if the permit valuation.is for $100.00 or less).
(J/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
t workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 & he Labor
Code, �I shall forthwith comply with those provisions.
Date: 1< Applicant WA
Warning: Failure to secure Wo k rs" C-Afnpe sat o'n 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 personl'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 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 ppurposes.
Signature (Owner/Agent)r RDate
' .
�. . BUILDING`PERMIT PERMIT# CONTROL#
970X014 5042
DATE v' . VALUATION LOT TRACT ;
JOB SITE
ADCRESS 53.763 �I:`�':1,.�i. DA 0111•1ZiaC3UiV
APN I `
1 %"Itil-1 1Jf4
OWNER • +
CONTRACTOR / DESIGNER / ENGINEER. j Y'
t � ��C��l�� �? r/;(.� �1'r:�s:9 ....
t;'�'l��,i"sit,.! !`3131.I.,�:�lstt •l
At5370 VH0,13 tHOON
)
LA QUf fr CA CIA 92�53
USE OF PERMIT
+
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PATIO C01tNVIUMON SY.
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)+Efsut�.lttr""gi,.i�.f,t� ��.�-CfUG-d2tl-uiJG '3.ZE.°;,t
,
,.T0Nt3 MOTION f )rf. - titI'811.1 101.000-;241.000PA
�` a t�f'{Yf i.l":1'1tJ �l i(f.if;C't4'fN !3�i)71'iAN C214Ff", '.
$245 45
LESS
$0.00
MAY 01 1997 101AL PF1001T R ON rai )ENOW
$245.65
OF LA. ON 11N
,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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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 Pibg. 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
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
Final
UU14 Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 4/14/97 APN # 774-154-014
No. 15423 Jurisdiction La Quinta
Owner NameGerald Flowers Permit #
N0.53763 Street Avenida Obregon Log #
City La Quinta Zip 92253 Study Area 111
Tract # Lot # Square Footage 192
Type of Development Residential Addition No. of Units 1
Comments
�,onvert existing patio into bedroom
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 192 or $ 0.00 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 n/a-27
Telephone:
Name on the check ' =
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson Exempt $0.00
Signature p� A Q n �p A l AA may\
Check No. n/a
40TICE: 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
bllect 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
CITY OFLA QUINTA
N� -& SAFETY DEPARTMENT
P��!i_.
fND T ONALL`
ACCEP ED R? ONSTRi. CTEON
SUBJECT TO NNSTALLAT►ON AS PER
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