SFD (9606-117)�? LICENSED CONTRACTOR DECLARATION
F_'hereliy affirm under penalty of perjury that I am licensed under provisions of
ryChapter9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force,and effect. ' .
License # , �� _ Lc. Class.: Exp. Date
k5• .. • t.e/�t►l�si
Date Signature".of Contractor—
OWNER-BUILDER DECLARATION '
(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 I am exempt, under Section , , B4E C •for this reason
Date +r 'jai h%Signaturetof Owner 'i
t
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 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' 1riJAif� 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 l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply wlth•.those o-rowslons.;
Date: -;21 it 1C� ± Applicant i"{ 1 y.- i.
Warning; .Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal. penalties and civil fines up to $1,00,000, 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^for nspe�ection purpo�se^s..
Signature (Owner/Agent) i'--'�� } i -L - �<=�^' Date
�" BUILDING 'PERMIT PERMITN ' ' ' , • • CONTROLav
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,
DAT VALUATION LOT;, TRACT
I ,
JOB SITE 44-6 A_# Mt .AIL0 0 MU V.b.. 1
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
#t,C'!GtM -NSNE LR,' :li31t WE &AS3SOC
Ai3G1'ssR, SWER.faF?A3i C•RGER &.t SSOC.
4146+Zi71M-865
oDsir 212
RAL -k i;3F.ly.1 R 'F. CA, 92211. i' . „ .
PALM M DESE I.2T i CA 92211.
(019)777-776t .
Cau lsfis
C !`lftf`1sjCi) 13: 4d'.1�1�w1si�ii+
USE OF PERMIT
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ARJPORT
RUCTION
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6RADINO ! lt. $20.00.
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A t' i' I P i�
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sV lv7l'tm GGN.,q Ruc7noN' atiN.D PI -AN CHECK
$4,476.88 ,
ES -FWD PETS
$0.00
U PE -NOW
411
$4o476,88
RECEIPTDATE
BY
DATE FINALED
INSPECTOR
i
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
o
Exhaust Fans
O.K to Wrap
L
F.A.U.
Framing
Z
Compressor
Insulation
O
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
8 Pl-
14-42
Final
Final
BLOCKWAL PP OVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
7f
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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 oe
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 7/10/96 APN # 604-262-002
No. 14675 Jurisdiction La Quinta.
Owner Name Roger Snellenberger Permit #
No. 44590 Street Milago-Dr.
City La Quinta zip 92253
Log #
Study Area 233
Tract # 23913 Lot # 46 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 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 1.84 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. a'
Fees Paid By Roger Snellenberger &Associates, Inc. ,TeleiihonF' 777-7766
Name on the check l jzw ftp
By Dr. Carol McGrew '•� t '!G
Administrator in Charge
Fee collected /exempted by Pauline Pearson Pavment Received $3,707.60
Check No. 012833
Signature
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
E'` Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting