SFD (9606-112)LICENSED CONTRACTOR DECLARATION
.Thereby affirm under penalty Of perjurythat I -am licensed under provisions of
6
Chapter 9 (commencing with Section 7o00) of Division '3 of the•Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class. Exp. Date `
Date "Ik•� C; Signature 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
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):
O Lam exempt under Section "r B&P.C.'for this reason
Date Signature of Owner r '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under ;penalty of perjury one', of the following declarations:
O I have and will maintain a certificate'of•consent'to self-insure'for workers'
compensation, as -provided. for' by Section 370'0'6f the Labor Code; : for the
performance of the work for which this permit is issued. k
( ) 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.
STATf ,r i.}'t1b 5..
(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 l should become
subject to the workers' Compensation, provisions of Section 3700'of, the'Labor
Code, -1 shall forthwith comply with those'provrsions.
Date: 12( Applicant f„r,,,.C.uv,._«:,r¢3st�;i' �:•
r
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".1set 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..,
I 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. -1 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 fo.r inspection purposes.' `
Signature (Owner/Agent)""' "' Date
BUILDING PERMIT : PERMIT # :`-°°"T4°`# 7
®�
_
DATE. �� VALUATION -LOT •��' TRACT
-.
' !1'71w7E/S►IS.: $�:2,8:,(r#d4;1:i! '. ��11'e f:�
JOB SITE `
APN
ADDRESS
44- 535 Id 11Ad6i D.RIVi
:.:604-161404 jz
OWNER
CONTRACTOR/DESIGNER/ENGINEER
5 0C
a���",. l j:i1R,ri> &
SN"' SC
.o�,
41-96; 80 AC2DWAUIP ,S`t.I.l'I E 1
,Ac.
.414965 Wt1IW AlA 5.561 i'F 212
PALM, DESEX � (A _.9221Y '
PA1.81 DESEIRT CA 92111
6197777766,1 COLA ISSR
USE OF PERMIT
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CISMMR.Ut; {'•ION RM - 01-10*€ 118-000 S714.:0
Mr t1C'Al. T 1i iali�ClCi�-�1 •1^fit.0
aa1.lui=�-ora
i :wall o r;1-% .-0041.9-000 SM4,00
11*T011,(:o 1YiO'1'UDN PLZE -1t ISM " '101-0%)l;241ADOO $12.17
KrNFRA81Rtlr: URE: F1:.- Z25_Op-443<342 $2737*
ART TN'!.'ft11'ST::l.C.P1.:.AC„'1' S-'.P,ds 3!r 701-000:'75$-000
'w'•.. �}}}+++���ur° 1t r�yy��c n�� �� �•ry T. �. �'Ag �•y ply y� CHECK
eJ ' f1: �J l a� (PION' t L'�:C CC i�f.�tV t'Lt�eO 1"LA'UV 4I'l,Ay�,+,K -
$4,476=
_ # LESS PRE -PAW FE, 1:S
$0.00
SEF 1. .1996;7.8
p By {
RECEIPT,
DATE, ' . _
BY.
DATE FINALED r!
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs A 1
Underground Ducts
Forms & Footings 1,60Ducts
Slab Grade t.
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing 7
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 A PROVALS
POOLS - SPAS
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
Final.
Utility Notice (Gas)
ELECTRICAL A P OVALS
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)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 9/12/96
No. 14842
Owner Name Roger Snellenberger
No. 44535 Street Milago Dr.
City La Quinta
APN # 604-261-004
Jurisdiction La Quinta
Zip 92253
Permit #
Log #
Study Area 233
Tract # 23913-6. Lot # 41 Square Footage 2015
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 5.00 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 1.84 X 2,015 or $ 3,707.60
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 Roger Snellenberger & Assoc., Inc. " Telephone ,777- 7 766
Name on the check -'
By Dr. Carol McGrew �, w
Administrator in Charge<
Fee collected /exempted by Pauline Pearson Payment Received $3,707.60
P1'9
Check No. 0013514
Signature RA,, ,Q l'u AIA A QA�✓�
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