AR (0312-112)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
722925 05/31112C
'-"Date � r �!f ��'"•7 Signature of Contractor.-- Z_ f_ �11Z
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 a 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 IfXl��V1pi 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 provision le
/Date: �7 :o r % .` Applicant e' i -u SSI
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 or purposes.
Signature (Owner.. gent) - /.�A Date i 6 fair
• BUILDING PERMIT
DATE + r Tt {/VALUATION $26tS LOT
JOB SITE ��r
ADDRESS _ ,?� ,#1411fA F ,4,!I
IOWNER
TClA & "n3J1N'CY LA'UTMo' M
4 9-4:5 3 .MON 'TA NA. WAY
I=ra Q11iNIA.
I USE OF PERMIT
PERMIT #
-
• �Pt - -
APN
TRACT 287.12
(54.9-2510-02,01,
CONTRACTOR/DESIGNER/ENGINEER
73-195 UOADAIXTRE AVE
CA 922153 PATId1 DESERT CA 122611
(760;241-0102 CB114 5812.
264 SF ADDITIOM TO IMIS T INN QUEST HCaUSK2001 CSC
OU2TOM CONSTRUCTION 264,00191+
I±.g'" 3FKAI ) COST OF COMIN[y'C"$ MIN
x'11Mff#n.Y. SU4KAARY
PLAN f HFICK FITE
1014 9000-439.318
S140A
CON STRUCT1014 FEZ
101•-000-4118-000
$aiuo
MECHANICAL FRE
101-000-421-000
T24,06
ELECTRICAL IFF -P,
101-000-420-000
$22.50
STRONG MOT 100 RE - 'REMID
101-000-241-000
$2.06
o � �
MAR ,112004
D PLAN 01-M-0 K
LYSS M-PRMP? iS
f
TOTAL PERWCMT.8 DUE NOW
RECEIPT DATE' ,fJ f BYE--- IDATEFINALED INSPECTOR
v
$4.04.96
�tT.00
�4415i
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
3— _�
Exhaust Fans
O.K. to Wrap
Framing
��:�/ _
3�=y
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali 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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Top Out
_ /
�r(
Plumbing Final
Equipment Enclosure
Shower Pans
OX 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 — 4
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
C
6
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District �4Sc<C2�0
47950 Dune Palms Road ¢BERMUDA DUNES
Date 3/11/04 La Quinta, CA 92253 RANCHOIANWE LS C7
� INDIAN WELLS ^�
No. 25629 (760) 771-8515: �,� P"LAQUINT��y
QINDIO y^1_
Owner Tom & Nancy Lauerman APN # 649-510-025
Address 49453 Montana Way Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # 0312-112
Tract # 28972 Study Area
Type Residential Addition No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 69 49453 Montana Way 264 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
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 facilities 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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $0.00 X, 264, S.F. or $0.00 have been 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 Exempt -Ken Cates Check No. N/A
Name on the check Telephone 413-9037
Funding Exempt
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Patricia Barbuzza Payment Recd
Over/Under
6
nature
NOTICE: Pursuant to Government Code Section 660f(l), 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 t e date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the Districtfs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
''- Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting