AR (9912-083)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
674074 ii 0 7i3V201
fctAate � +'� �� Signature of Contractor ---'
OWNER-BUILDER-DE..CLARATION
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 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).
( ) 1, 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:
Cartier Policy No.
.TA'11.1. 11U!l4D ii fer VN31x ,).H4
(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 tfiat�if I should become
subj�eet to the workers' compensation provisions of Section�3700 of the Labor
C9de, I shall forthwith comply with .those provisions.
.Date:� �is;�..'� Applicant/ j�
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.,l agree to comply with all City, and State laws relating to the building
construction, and hereby au horize representatives of this City to enter upon
the above-mentioned property for inspection purposes
��
Signature (Owner/Agent)Date �//91�.
PERMIT #
BUILDING PERMIT
9912.1083
DATE VALUATION �ZII, i irL LOTSy TRACT ~4911
1 _
JOB SIIE
ADDRESS 49-452 MONTANA WAY
APN 60-210-007
OWNER
CONT�R�ACpTOR'//DESIGNER ENGINEER
CONTRACTOR
(�� {{�/� A] (ry
VE
T. D. DESS R",' .M., Y?L�.A,,,iPh-Ii N i.
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{NNGINpEER y, y*
I IPAj:11."S �rY�.� 9[ l\i.%\.ri10 i'4 �
P.O. BOX 171.6
79-295 RANCHO .LA UUIJ,+I'I'r\.'OR,
L..A QU.KrA CA 92253
LA QiiiN"i'A CA 92253
OF
(760)171-1911 CRIA 2996
y
USE OF PERMIT
kPiStDW—I Ai., ADN V 10N
e.
iOD a 014 OF 0V I01IN-A - r fTA130) h1i GM- T SUITE TO MUM 'i !"l DE11
CQN.Tf.KUUr,10N (LOT 32)
C e iS 'Gha. C."vidaT,Ri ii: i tf'/iii .{i() S -F
` i. sq Eisii94, f.l \. �.sj Y. Vl �..V°ii�Y�. a:S ��.ls0I
ffi Y.Y.a�s.�.i3V
4:( ITL`.;'[141 $77.00
IANTICAL PE 101 -L00 -421-C()0 s� .54
:I t�r:CTRICAL F, il 101-000-420-000 59.52
PLMHI MOM !' HF 101-0004194M V9.25
STkONO VOTKYN r:r-,R - PESO) 1011 -00n-?41-000 $2..1'3
MIX ire 1:'LBLIC VLA ES-RCS1:L' 7011-0004255.000 $52.,98
;:1'3L3-T'tJ AI,t"(7 1"1Iti:TC�"tLON!1'Nt)!'I,ANC H�;�'K
X251.99
LJ<,SS Pt'U,,,-PA1D F1r1iS
$0.00
T MAL !'tt RIli!M rY FE1:9� S DUE NOW
$7.54,99
1
Y
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
OX. 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
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
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.��
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
C v
Desert Janus un►t►eu.ocuuu► L►stnct
47-950 Dune Palms Road
Notice: La Quinta, CA 92253 t
,Document Cannot Be Duplicated ' .760-771-85115
CERTIFICATE OF COMPLIANCE
Date 1/10/00 APN # 649-210-007
No. 19893. Jurisdiction La Quinta
owner NameTD Desert Development Permit #
No. Street SEE BELOW Log #
City La Quinta Zip 92253 study Area
Tract # Lot # Square Footage 1088 -
Type of Development New Residential Addition No. of units 4
Comments
SSA VIDA CIRCLE: 79-100, 272 sq. ft; addition of optional attached guest suite to house
der construction (Lot 66); and 79-111, 272 sq. ft., addition of.optional attached guest suite
house under construction (Lot 68). MONTANA WAY:, 49-452, 272 sq. ft., addition of
tional attached guest suite to house under construction (Lot 52); and 49-563, 272 sq. ft.,
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 -
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 1,088. or $ 2,099.84 ' 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/ Palm Desert National Bank/Judy Halpain Telephone 760-771-1941
Name on the check,
By Dr. Doris Wilson
Superintendent
Fee collected /exemRted by Ellen Patino
Signature /C) t -I.
T
Payment Received 12,099.84
Check No. 81519
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9"ay approval period in which you may protest the fees or other payment identified
Dove will begin to run from the date on which the building or or permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
Alect them on the District('s)(s') behalf, whichever is earlier. - -
. r
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