9802-133 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
/Date/,; ` `Signature of Contractor X11
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 Policy No.
(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 provisi6ns!
,/Date. : �, �N Applicant,l
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 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'
r
BUILDING PERMIT
PERMIT # CONTROL #
4,N ;>,433
DATE VALUATION i 1 eE9 Q e �E5 LOT
TRACT 6893
JOB SITE
ADDRESS 54
APN
767-^3 013
OWNER
CONTRACTOR/DESIGNER/ENGINEER
N ItI-',dtr(w1UFI'E
LA Oft NTA t °A ,,P 'o k
i A Ql )1NTAP
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USE OF PERMIT
A9)ON
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R 21998
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(IIIIIII VIII III VIII IIII 66
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K to Wrap
Framing
�l g ��,
F.A.U.
Compressor
Insulation
3�1G� �j7
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
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
t
Final
Utflity Notice (Perm) �"
COMMENTS:
.Svc F1v+-
LIL;tNbtU UUN 1 MAI; I UM ULULAMAI ION
hereby affirm under penalty of perjury that I am licensed under provisions of
FF- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
LW- " ` -OFrrofes ' nals Code, and my License is in full force and effect.
M M Lic se Lic. Class Exp. Date
LO
LU 296566 B 10/31/98
Z I, -Date Signature of Contractor
O 0
OWNER -BUILDER DECLARATION
LLll W n I hereby affirm under penalty of perjury that I am exempt from the Contractor's
NLicense 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
Cl) () I am exempt under Section 0&RC. for this reason
In
N Date Signature of Owner
OC\1
Q WORKER'S COMPENSATION DECLARATION
CrI hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
jW Q _ compensation, as provided for by Section 3700 of the Labor Code, for the
pFrmot
rmance of the work for which this permit is issued.
Q () 1 have and will maintain workers' compensation insurance, as required by
U "Q Sn 3700 of the Labor Code, for the performance of the work for which this
0) F- piis issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
ob O STATE FUND 1242713-97
g (This section need not be completed if the permit valuation is for $100.00 or less).
() Ic rtify that in the performance of the work for which this permit is issued,
I sha not employ any person in any manner so as to become subject to the
wor ers' compensation laws of California, and agree that if I should become
3 s BO to the workers' compensation provisions of Section 3700 of the Labor ode, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
;al
hall 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 cancellation.
I certify that I have read this application and state that the above information is
corre I agree to comply with all City, and State taws relating to the building
co truc. tion, and hereby authorize representatives of this City to enter upon
thA above-mentioned property for inspection purposes.
;ignature'(Owner/Agent) Date -
PERMIT p t �: CONTROLp
X02-133
DATE VALUATION LOT TRACT Q G
$21,611.40. V v
ADDRESS' 81-345 AVENUE 54 JOB SITE
APN 767-320-013
OWNER CONTRACTOR/DESIGNER/ENGINEER
MERV GRIFFIN EAST VALLEY CONSTRUCTION
81345 AVENUE 54 54880 AVE. ALVARA.DO
LA QUINTA CA 92253 LA QUINTA CA 92253
(760)564-4844 CBL# 1961
USE OF PERMIT
IIIIIIIIIIIIIIIIIIIIIIIII 61
IE
398 S.F. ROOM ADDITION.
ADDITION 398.00 SF
ESTIMATED COST OF CONSTRUCTION
21,611.40
PERMIT FEE SUMMARY
PLAN CHECK FEE 101-000.439-318 $146.25
CONSTRUCTION FEE 101-000-418-000 $225.00
MECHANICAL FEE 101-000-421-000 $35.00
ELECTRICAL FEE 101-000-420-000 $28.93
STRONG MOTION FEE - RESID 101-000-241-000 $2.16
GRADING FEE 101-000-423-000 $20.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$457.34
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$457.34
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201619-775-3500
CERTIFICATE OF COMPLIANCE
Date 2/26/98
No. 16675
Owner NameMery Griffin
1
t
APN # 767-320-013
Jurisdiction Indio
Permit #
No, 81-345 Street Avenue 54 Log #
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 398
Type of Development Residential Addition
Comments
kddition to kitchen
No. of Units
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 398 ' 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 Tele hone 564-4$44,
Name on the check
By Dr. Doris Wilson
Superintendent - 6
Fee collected /exempted by Ellen Patino Exempt
t
Check No. N/A
Signature
IOTICE: 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 of 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
.,,act 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
f
Coachella Valfey Unified School District
P.O. Box 847, Thermal, CA 92274
(619) 399-5137, Ext. 235
Project Name:
Owner's Name: Mery Griffin
Thls sox For District use Only
DEVELOPER FEES PAID
AREA:
AMOUNT: RC:PT.N:
CK. p: CASH:
INITIALS: DATE:
CERTIFICATE OF COMPLIANCE
(Government Code 53080)
Date: January 22, 1997
Phone No. 564-4844
Address: 81-345 Avenue 54, La Quinta, CA 92253
Project Description: Room Addition (one)
APN: 767-320-013
Tract #:
Type of Development: Residential xx Commercial
Total Square Feet of Building Area:
Lot #:
622 Sq.Ft.
Industrial
Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this
statementement under penalty of perjury and further represents that he/she is autorhized to sign on behalf of the o er/developer.
Dated: / -6622 —C? % Signature:
SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE
SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE ONE):
Gov. Code, Gov. Code Project
53080/65995 65970 Approval
Number of Sq./Ft. 62?
Amount per Sq/Ft. $ 1.84
Amount Collected $ 1,144.48
Agreement Existing Not subject to fee
prior to 1/1/87 requirement.
Note:
By: Foch "Tut" Pensis, Assistant Superintendent Administrative Services
Administrator in Charge
Certificate issued by:
Marcela Valdez
Signature:
INOTICE: Section 66020 of Ore 4ovenuunn Code enacted as Assembly Bill 3081, set forth as Chapter 549, Stahrtes of the State of Califonria, 1996 eff*tive lmr. 1, 1997, requires that this school district provide a written notice to
die project applicant at Ore tune of payhuehht of school fees, mitigation payment or other exactions. Tltis notice is to advise you that any protest in regard to such amohnrts or die validity thereof ur accordance with Section 66020
of Ohe uovenurhent Code mrd other applicable law, conunahces with such payment or performance of mhy other requirement as described ah Section 66020 of die Govenunent Code. Additionally, this notice advises tlmt die
protest thereof unhst occur within 90 calendar days thereafter.
Note: AB 2926 and SB 201 fees are capped at $1.84 per square foot for all residential construction, and at $0.30
per square foot for commercial/industrial projects.
Dev. Fees Disk: Misc\Cert-Corn.Sam. (REV. 1/97)