SFD (0107-012)LICENSED CONTRACTOR DECLARATION
Y I *eby'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, /11^ Signature of Contractor ,KS•r 7.-
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
contractorsto 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.
- (,,,)o'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.
3104. nIr Zi'f,1J�.t"'. 22943 k NIT OJ044.01
(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 pro visions of Section 3700 of the Labor
Code, I shall forthwith comply, with, those provisions.
Date: "" / n • Applicant � "A'. A ---
r�P'
'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'`repreesentatives of this City to enter upon
the above-mentioned property for4inspection purposes.
r
Signature (Owner/Agent)'"Y�Ep� Date
BUILDING PERMIT PERMT"
DATE 1 / VALUATION LOT 0110./.-012 ':1,TRACT
sB147i a1J
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
YwIE)T.3 yriVI ' COVE .DEVE'1..Cbk^'!1�.1NT RIM
VM:i IAM R`{.TMLL P.6GERI
Q Box 3576
569100 M.1,,'s ON 3"1' ,
?,FR.ir..MDESMIRtT CA 9226a
TH fi:MAL 'CA
(7314f 1454
USE OGFI PERMIT
T,'�7xiiN4.YLii L'�'!+L71f�.m J. I:f V'Vd:.1.i�.aL.tir "Nl4
"IMT i'3C11' Ii4C17UT1 13IC' �J:A1�f.i:, P001,f 3R .R:ltt9/�"'b%rS Y
APPROACH.
'1'UC`1' WNS i RUCTION 1.,,'sQ 7. t3U ;1:tr
I
Ftw±Z'f,#3i4�it.TS.f:° ,. 36.00 sib'
OA.itAGEIt`,,ARPC3RT 518,00 SF
04 S".�X.f T.FMId' COST0A'" C�QK IRU f'rpG1tii'l."f
w' Iew
(;°ON14T UC"TION RE- 101-000-418-000 SM11.50
.121,AN CHECK Kit $03.64
R11 DU£IT 101.000.439-115 •1250+.00
F.LF,cIP1"b1(,'AL MR 1.01.000.4.20.000 $106.01
.P>-.UN181140 FEE 101 -.000-419-ow T• d, L'£f
9l;'}WHO Mf.D`1ION F-0-, -R OW 101-00) 24.1-0010 $11,3@
C31k3.t;1A]+iO 301 -#JO D �9 S30fJ 3[t'.t79
D. E:VF1A5F19.R IMPACT PACT 1`RE �►
1 REMSE P1..AN 101-000.44��yy••pp�9pp��••��rr��g&+�
F��
,ry,/+�e�t� ,.�rypy'�yy♦�`!t
6,.'k./L�SJ.ILt UIC-101:Y Q�." r.Ab'�
�ll.✓ (�
�y (}/�S747g.3"d.4.AAAL
'i3,U8.03
i
RECEIPT
DATE
:
BY
DATE FINOLE D
INSPECTOR
Ile,
,
1`/(
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 Deck8
, (G • O (
s�
Exhaust Fans
O.K. to Wrap
0 (
SZ
F.A.U.
Framing
_,—q-
S7
Compressor
Insulation
I
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
7,
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_
��1�
��
Pool Cover
Sewer Connection
3
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
��—��
54 --
Utility
Utility Notice (Perm)
_ 7 r
9
� t
Building
Address
Owner
-M1
�6D -
P.O. BOX 1504: Air
78-495 CALLE TAMPICO APPLICATIO LY r Q
AV, My�J1UINTA, CALIFORNIA 92253
Address P.
City'
lZip
Tel. �,;•"
241111
Sq. Ft. Z
Sae {a
Contractor
6W
Address
_,.!)+ 4"e) S l
y
Cit
City
Zi p
Tel.
L
State Lic.I J
& Classif. Z
City
Lic. #
Arch., Engr., I r
Desig ^A �ji. je;Q F-, .JT�E
Tel. k
• el 171-4 1 1122.1
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
6 OWNER -BUILDER DECLARATION,
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to 'its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500).
I, as owner of the property, ormy,employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that Such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of Sale.)
(A I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
i 7 1 am exempt under Sec. B. & P.C. for this reason
Dale Owner "
WORKERS' COMPENSATION DECLARATION S,
1 hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
t7 Copy is filed with the city. 0 Certified copy is hereby furnished.
r CERTIFICATE OF EXEMPTION FROM -
WORKERS' COMPENSATION INSURANCE
-(Th is section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, after 'making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name i-
Lender's Address -h
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant —Date—
Mailing
ateMailing Address
City, State, Zip
ILDING: TYPE'CONST. OCC. GRP.
'. Number 0 i 7
)al Description L 0'r t'S L`'>y- tom'" t
eject Description% 1
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
Igf►LIalZi
Issued by: Date
Validated by:
Validation:
'WHITE = FINANCE YELLOW = APPLICANT
PINK = BUILDING DIVISION
Sq. Ft. Z
Sae {a
No.
Stories
No. Dw.
Units
New.' Add ❑
Alter ❑
Repair ❑ Demolition ❑
L
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
Igf►LIalZi
Issued by: Date
Validated by:
Validation:
'WHITE = FINANCE YELLOW = APPLICANT
PINK = BUILDING DIVISION
1.
Notice:
Document Cannot Be. Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date .7/26/01 APN# 773-333-012
No. 22321 Jurisdiction La Quinta
Owner NameMountain Cove Development, Inc. Permit #,
No, 52-970 Street Avenida Mendoza Lag #
city La Quinta. zip 92253 Study Area
• f
Tract # Lot # Square Footage 1347
Type of Development Single Family Residence No. of Units 1
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 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
2.05 X 1,347 or $ 2,761.35
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/Canyon National Bank - L. Shields
Telephone X399.-1200
Name on the check
By Dr. Doris Wilson
r
Superintendent,
Fee collected /exempted by Ellen Patino
Payment Received 2;7635
Check No. 07735 �
Signature
F
ICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
e willbegnt, run from the date on which the building or installation permit for this project is sssued or on which they are paid to the Districts) or to another public entity authorized to
ct 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
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single.family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is to determine:
1) that the proposed house design does not duplicate .the same architectural style of any
house within 200 feet of the applicant, and/or 2) if there is a need for the applicant'to file for
Master Design Guidelines. If the applicant does need to file a Master Design Guideline, please.
transmitted this information to the Building and Safety Department as part of your correction
list. Please attach additional explanations as necessary.
Mountain Cove Development RFc�oF�Rp9p
APPLICANT �
111VFo T c s
SITE ADDRESS 52-970 Avenida Mendoza ��-1,1,—
APN 773 333 - 012 CASE NO.: 2001-467
LEGAL: LOT 15. BLOCK 147 UNIT' S.C.@V.L.Q.
CHECK AND APPROVED BY: DATE:
Inform the assigned Building pian checker upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Verify legal and APN information
X
Consistent with MDG on file (as
applicable
N/� Crr�` s� M b
MDG filing required (5 filings since
9/3/98)
'� 4>- W
t -i UA -Em ✓ tQ �)
Architectural variety within 200 feet of.
,the surrounding area:
� Colors
_
Materials
Architectural design features
t
�
cOM101"
QQR ►�
Doke
Other Requirements:SEN�
ollffo
t
Certificate of Occupancy..�
-City of La- Quinta-
Building:and
Safety Department. OF-��°
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the, City regulating building construction or use. For the follo -wing-
BUILDING ADDRESS: 52-970 AVENIDA MENDOZA
Use Classification: SFD _ Bldg. Permit No.: 0107-012
Occupancy Group: R3 Type of Construction: .VN Land Use Zone: RC .
Owner of Building: MOUNTAIN COVE DEV. INC Address: P.O. BOX 3578
City: PALM DESERT, CA 92261
By: STEVE TRAXEL
Date: 10-10-01
Building Official
POST IN A CONSPICUOUS PLACE
r