0001-053 (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 f .the Business and
Professionals Code, and my License is in full'force and elle t.
' License # Lic: Class Exp., Date-
01i e
N 1999
Date - J wSignature of Contractor
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
I
ale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively, contracting -with licensed
contractors to construct the project (Sea.. 7044, Business & Professionals
Code). r"
O I am exempt under Section • B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury 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.
•�4a,m{ c»':r.c� r.•i1:8V'r r t�,7r*�1 �ncJ"nl
.(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 provisions.
,.Date: I Applicant %
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, indemnity
& hold harmless the City DULa 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
BUILDING PERMIT PERMIT#
talism-a�53
DATE VALUATION $36,541" LOT TRACT
JOB SITE
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
rrn A i it iu'(1-1312fl'P` bI, l.r.",,t,MV e:'rt7XA? A W1'
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'147
54-100 AVENIDA ,t1ct0N'i t ZUUT.V1.A
72.845 ARBOLEDA A'VT .N'UE
L.A. QUINTA CA 92253
PALM,, DFSN.1t7' CA 92260
(76q)776-9508 CSL# 5937
USE OF PERMIT
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rt,a3:>7ITi Iv 673.00 qSr
nA +t♦1a '10ta 0 A'7•ilr g�•� !"riri^a' !'i a'M'YAtQ'4" .x r9'� iPslt
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•3C, t..AD !9
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PLAN CHECK FE:t✓ 101-000-4-40-:318 $214,50
i7�r)INS'!pIV i*C�1"�{t'KYN F'1?T{
0
1{ ',li.jl rt.lt{JV l` L. FEE rLS l l! (^1�15i i1"Ri1v 1^ V iJ V 919.50
I I.ECTF!CA , Fa, 101.0)0-4204WA)
LUNRAINCE FEE 1014)f)O-419-000 $bil.usr
R-PROMC'W)1'1CiNFi•1v._tii,�S(i !(il•• 0),-7411-f�(iQ $3 45
OR ADINO, FEE 10.1-00044-000
1,�4-'MTA.1., C�ON� l f(71'10N AN) PLAN CHECK
t•C�l,��!
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1
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71'0 Mi.— 'F dt ti IT 1~+ C CS DI l (i+.: NW' W'
$641.9
RECEIPT
DATE
BY
l
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 — Q , p
Exhaust Fans
O.K. to Wrap _ C,90
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPRVALS
Waste Lines a9-�
Water Piping 3'
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure ,
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 24 00 s'
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Utility Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 1/27/00
No. 19972
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN # Not Available
Jurisdiction La Quinta
Owner NameGerald Egbert & Wendy Stewart
No. 54-100 Street Avenida Montezuma
City La Quinta zip 92253
Permit # 0001-053
Log #
Study Area
Tract # Lot # Square Footage 673
Type of Development Residential Addition
Comments
i73 sq. ft. room addition.
No. of Units 1
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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 673 or $ 1,298.89 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
- - I
Fees Paid By CC/Union Bank Of California/Page Quillingf' '
Telephone�76U-776:950�'.„
Name on the check ° I
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Mary Ann L. Borja Payment Received $129ff.89. -`-
��� Check No. 6529039
Signature
NOTICE: 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
collect 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