AR (9912-086)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty,of perjury that'l 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
07/31/20(
/at�� �} Signature= of Co t actor] + ��
r r' �
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 providedfor by Section 3700 of the Labor. Code, for the
performance of the work for which this permit is issued.
( ) 1 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:
Carter Policy No.
STAT i'P N. 0 •<e rr 9m
(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
9su fect to the workers' compensation provisi6Q-.S of -Section 3700 of the Labor
de, I shall forthwith comply with;thbsse provisions.
✓Date: Applicant C i
Warning: Failure to secure Workers' Co pensation 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
tfie above- mentioned property f&Jnsp60tiO. purposes.
/Signature (Owner/Agent)--';;'-"' Date
-WILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
74 28912
JOB SITE APN
ADDRESS 4 X-563 I jIONLUNA WAY .649-210-007
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T.D. l��i i�..r'. Yr� P-.1 i�t�. it �v SPARKS :'ON77b`i Ul.,.TR IN
P.O.2305," 1,,16 7ro 295 RANC.t-iO Lh.-Q�Ut,`J'1A a)it.
LA OUDI Tri1. CA 92253 LA QWN T.A. CA 92253
(750)771-1941 Cle1.4 2996
USE OF PERMIT
RRSIDEWW, ADDITION
'r
.A.Dr 1TION OF OP ['ii_SWi L k TA,LrMD M CRIST NTTF. Ai ifous% Utvuam
F
CONS YI.'(UC T' GNI (:.O':(' 74 . I'1 , C I%C:K•F96 PJMJ_f`O 7S°;6 ,E'UR
10113L'il;k'LU ISSUA1v'C-r• O•tl SA1Lb3: X RUCT UCE.
f} �r
CUS T ONI CONST, RUC710N 1 272.00 alp
21,In.. o
SB -TOTAL WNSTRUMION ANIS PLAN C,14EC,.K $203,53
ALF -SS PR•E413A1..4D 11TES I $0.uo
`1''OTAL iRyEd7i'i!eIT FEES DUE 1"40W.. I 5203.53
RECEIPT I DATE I BY " I DATE FINALED I INSPECTOR
CONSTR.UC t`f:C)N 1 S
101.-000-418-000
t $77.00
f +, f t4 C"E'Ors:14-19
1.01-Q(}(i 9'.118
$1.7, x G
,I4f R. t,;.41c`1.�f'�l1C,r+L F'6131
101-0001,11421 ^000
W.50
La LC:wi:i.C:il3., Tilt
i 01-000-420-000
$9.52
RIJI&I-'"S:tNO FEE
201-000-4194H00
$ t 9.2y
e3710N+33MO IOT4FE-F-RFSiD
1.01 -OW -141-000
$2,12
ArVr ,,R4 P ( LTC MACUS - IMSIM 701:.•000.255.000
$S2.Sp
21,In.. o
SB -TOTAL WNSTRUMION ANIS PLAN C,14EC,.K $203,53
ALF -SS PR•E413A1..4D 11TES I $0.uo
`1''OTAL iRyEd7i'i!eIT FEES DUE 1"40W.. I 5203.53
RECEIPT I DATE I BY " I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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 8 Controls
Party Wall Insulation
Condensate Lines
_
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
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
COMMENTS:
`//G ?'✓ •�
(
�6 v
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
Tema. Use of Power
Final
Utility Notice (Perm)
1lesert 6anos unineu 3enum ►oistriu
' 47-950 Dune Palms Road .
Notice: La, Quinta, CA 92253
Document. Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 1/10/00 APN # 649=210-007
No. '19893 Jurisdiction La Quinta.
Owner NameTD Desert 'Development. Permit #
r
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
CASA VIDA CIRCLE: 79-1,00,,272 sq. ft, addition of optional attached guest suite to house
under construction (Lot 66);'and'79-111, 272 sq'. ft., addition of.optionabattached'guest suite
o house underconstruction (Lot 68). MONTANA WAY: 49-452, 272 sq. ft., addition of
optional 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
Lhas 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
PPLICABLE•This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of i
1.93 X ' 1,088 or $ 2,099.84 the property listed above and that building '
i..
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 /exemQted.by _ Ellen Patino Payment Received $2,099.84 , "
Y
Check No. 81519
Signature
10TICE: 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
bove 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
ollect them on the Districl('s)(s') behalf, whichever is eadier,, -
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.