AR (9903-190)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
i11— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) c7 License # Lic. Class Exp. Date
w
oZ ti I/Date r Signature of Contractor
CID
O�
t� U C:) OWNER -BUILDER DECLARATION
HWt2 I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
ul I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O aN,
a Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W 4- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q L) (4r) I have and will maintain workers' compensation insurance, as required by
O Section 3700 of the Labor Code, for the performance of the work for which this
11 rn FQ- permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
Cb
CY .11TI 11.7 iJivL1 fRi{�rf%�ni i'+y i
g (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-a's to'become subject to the
workers' compensation laws of Californian a agree that if l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
3 9de; I shall forthwith comply with those provisions.
Date:. Applicant-
Warning:
pplicant 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 representatives of this City to enter upon
the above-mentioned property for inspection n!purposes.
%,Signature (Owner/Agent) �- Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
�21,18tt.tTq t 28640
.L,IC
JOB SITE
APN
ADDRESS 78-9tOR'i1S.yiOl`n ilii %'f;Vb' :Si
649-210-603
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T.t). DE-811P,T
SPARKS C ONS4 UC710N
P.O. BOX 1716
79-2951;UkNC.t10 LA, QUIN['A 1)kL
L1 QU1N'1'A CA 42251
1.,A QUINTA CA 42253
4 7601771-1 94 1 CB110 2Q06
USE OF PERMIT
Rk".)[1ai id'NA!, r1F�U1'I!t iN
4)DFf1C#N t-6 OPTIONAL ATT At111s1) k1i 00EST 5151 G
s:73 'ii )1i CONSTRUCTION :'.011 Sr.
EST IM AT IEM cas i or !Y)�'S'1'fi i;._ � ii�;L'
«,..1.40.39
PERMIT FEE SUMMARY
C0N8TRt1CfIuN FEE 101 -W)-418-000 $77 tis
P1 AN t'" WCK F'FF 101-tN1fI-,13103(2 +IhR
T' IECI111,1v` CAI, FIT it)i 000 -3'1.1-(1411;
).t.k kICAL fIstl 101-66 -42040 39.3
1�I,t114�#biT3t.1 FH.1s ill-tliHl-=lt9-i)t)t) 31+i.w�
RIV01NO N40TT0N1Tr'.i1#^811, 101-411((1.74#_0(1fi S7 }?
INMZA.3=UC'11JIXI4,J 225-000-413-342 S:u32.93
ART 1N PUBLIC PLA+: k8 -1t6SIC 701-1)(10-255-fatxi $$21,98
.:1 TIi_'IYITA 1, C"C)N PI? 1_I( "T1(lfv gNil z>i,1!ly C}tNt'fi.
$iV 07
Lf?:;S a".t1! -Pi I 1 S
ppa
TOTAL P1':1tMiT FEi;S 11111?; NOW
W7.92
R�EjCEI T 1%, jj
DA E
BY
DATE FINALED
INSPECTOR
a , 1\% C 'A
r
INSPECTION RECORD
OPERATION j
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
Exhaust Fans
O.K. to Wrap
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 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:
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) (/
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 3/24/99
No. 18487
Owner NameT.D. Desert Development
y APN # 649-210-03
Jurisdiction La Quinta
No. 78-920 Street Mission Drive West
City La Quinta - zip 92253
Tract # Lot #
Type of Development New Residential Addition
Comments
32 sq. ft. addition to house under construction
Permit #
Log #
Study Area
Square Footage 272
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 mobilehoines.
It has been determined the above-named owner is exempt from paying school fees at this time -due toAhe following
reason: V ^'
^s
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 272 or $ 524.96 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/PDNB/Judy Telephone 771-1941
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Adriana Gauto Payment Received $524.96
Check No. 74801
Signature
NOTICE: Pursuant of Assembly ill 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 '