RER (0306-170)LICENSED CONTRACTOR DECLARATION
0), 7 1 hereby affirm under penalty of perjury that I am licensed under provisions of
r- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
,t, C" W Professionals Code, and my License is in full force and effect.
O =),c,) License # Lic. Class Exp. Date
I --
LO
w ;i t /j 12 J l2r
'
o Z P '°Date 7 " `' Signature of Contractor���
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�p OWNER -BUILDER DECLARATION
dW 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).
c0() I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
ON
d SQ WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
Lo 10�
p () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn permit is issued. My workers' compensation insurance carrier & policy no. are:
? Carrier a3T.IItH'Ei1dD Policy No. fti-Of; 11363
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J (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.
,r Date: 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, 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 purposes.
Signature (Owner/Agent) - Date'`
BUILDING PERMIT
*,PERMIT# r
iK'4ilF-a. Jai
DATE `r -'VALUATION'' y =COT TRACT
�-�
V :448
JOB SITE
APN -
ADDRESS rt�,b%I4, VZCi��
l� 0-1.91413%
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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144,5 mwmwwr WAY, s13l1!r: 203
LA. QM4TA
-
f1�JQ 4.16- 14�A CM.19. 55rk
USE OF PERMIT
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IsupplKe., mw m PCMA 0104-128,x143 1 hid
sa°i�niy f>7f2� :iO3
CONTRAC'17Aik1OUNT :lA
XS1'0407D (N)ST OF COJ't Y RIX 100
4 7,1X'
PF. Rmlf VER X4 &1&1qY
40145—TRUCTION PP1219 .1.01 4XIC-41 80X1 $.7210
PLAN CHECK rEg 101-0004:�9-31181 $37.50
IIAE"Kt;'PSJCAL Re 1,+01.00-4'ZI-iM $19.0
H.1,M: `7RJ A1,VU,, 1CIA- 0010-•20.1,100 $1745
;3'•?DOJO MOT!OX WE,. RLOW 101.000-24 : -vC U °1,.1" .
rTC.:J.3t •',i t1tl.S '�7u l...C,.tVaed.,U.l.i w�.�l�li'� .t"+!� 'I �9.i1"aF� �.,L'�L'��rJ.W
6/� �57. 9'„�
L232 ,PPJ,7?, A11> F.7E Z
'!OTALPER NUT '11XS1PI;'VV` W
,
$196,ii i
RECEIPT
DATE' r +I /
BY '''�.,w
DATE FINALED
INSPECTOR
:y
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
Exhaust Fans
O.K to Wrap - ly
F.A.U.
Framing 67 IF— Al
Compressor
Insulation -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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 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)
COMMENTS:
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1
A
X
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Bin # City of La Quinta �"'�`"�
Building ar Safety Division �Ec pN ' o
Permit # P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Project Address:l/Gw % �cR 2] Owner's Name:
A. P. Number:
Address: /
Legal Description:
Contractor: yam/
Address: �� !�
Cin. ST. Zip: LL 3
FTelephone:
Project Description: �1" ooJz L /
City. ST. Zip:
Telephone: y
-
State Lic. #: �%%� City Lic.
Arch.. Engr.. Designer:
Address:
City..ST. Zip:
Telephone:
State Lic. #:
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: J GST (sem/
Sq. Ft.: 70
# St ries:
# Units:
Telephone # of Contact Person: (., O a 7 " �, 8�
stimated Value of Projec . 00-0
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
I Submittal
Req'd
Recd
TRACKING
PERMIT FEES
21
Plan Sets
Plan Check submitted
-';IX-1,3
-13
Item
Amount
Structural C21e5.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"d Review, readv for correctio slissue
iL
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
10Grading
IN HOUSE:-
'^' Review, ready for correction<95*Developer
!is ue
47
Impact Fee
Planning Approval
Called Contact Person
(t (?j
I.P.P.
Pub. Wks. Appr
Date of permit issue
6
School Fees
Total Permit Fees
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CERTIFICATE OF COMPLIANCE
Desert Sands Unified. School -District qC:)
'47950 Dune'Palnis Road z °
Q'. BERMUDA DUNES r
Date ' 6/16/03' La Quinta :CA 92253 � Z RANCHO MIRAGE. �
' �. INDIAN WELLS
No. 24548 , r x.(=7.60) 771,8515 �; � PALM DESERT �
LA QUINTAINDIO
^�y
.. -
Owner Thomas F & Billie A Dimare APN # •646=191-0.07
Address, 49963 Avenida Montero Jurisdiction La Quinta
City " La Quinta Zip 92253 ! Permit # 0306-170--
Tract # 3448 f Study Area
Type: Single Family Residence No. of Units
Lot # • . No. Street `S.F. Lot # No. Street S.F.
Unit 1 . '. • 49963 Avenida Montero 70 Unit 6
Unit 2 Unit?
Unit 3 Unit 8 T -
Unit 4 Unit 9
Unit 5 Unit 10
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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason:
Residential Addition*500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to
Education Code'Section 17620 and Government Code 65995 Et Seq.
in the amount of $0.00 X 70 S.F. or $0.00 have been paid for 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 'Exempt - Scott Russell Check No.
Name on the check ' Telephone 760/275.3180,.
Funding Exempt _
By Dr. Doris Wilson ,
Superintendent
Fee collected /exempted by: Sh _ MCGilvrey
` Payment Recd' r Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d) is 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 issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document.NOT'VALID if Duplicated 1.• f• d
Embossed Original -'Building Department/Applicant Copy - Applicant/Receipt Copy Accounting s