SFD (9510-015)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my -
License is,in fulAYrceirand effect. S131196
License # tA. Lic. Class '_'; Exp. Date
Date ,63 /,eSignatureofContractor.
OWNER -BUILDER DECLARATION
I hereby affirm 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).
( ) 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.
() 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.
(This sectia 1n d' of & completed if the permit valuatio1Y for•$ 00.00 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.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful andshall
.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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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. 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 for inspection purposes. ,
Signature. (Owner/Agent) Date
1?
ALC>r
R�U.ILDING'PERMIT
PERMITi,v, QC_�il
tai s
a•u
, r .,,
DATE• "'
VALUATION ' LOT
TRACT
JOB SITE ADDRESS 'J"F&H to VC, IVeVVAIlfKO
APN
OWNER
CONTRALTO
4v.tI 3. COX° & SONS
1 Cox
66900 ®1L 0NI RD.
P.0, BOX 9677
P,ALnt DEMtT CA ,P226]
PALM. DESERT CA 92261 •
(619)251-3780.
DESIGNER/ENGINEER
r
e,F
USE OF PERMIT
PF.IMIT INCLUDES 130 L.F. OF -THIGH GARDEN VVALI.:MAINI'NG' WALLS t1N)YOR POOL
PERMITS TO )iii ONTAMF D SF_PAR.A'.I"E'f Y.
FEE DESCRIPTION
FEES
"I'ItACT C014,S'IXOC!`IQN 1.,257.00 3"
PO}iG' YPA'rid 78.01) .SI:
7:
GABA WCARPDXf 504.00 SF
1'i,9TIMI ATED COST101FICONSTRUMIONT
31,:,15,5.4f"1.��
KiMMITFEE SUMMARY
FM D137 5ff 4-noA110
CON'S'T'I;d,J l'I1-->N FEE 10:9 •"-419-000
WMWICAL FEE 101wo(10-421-000 $49.00
-"1,F 1,'_RTOA_t, ms's !01-000-4$24)-000 $07.50
'LL3NWiNG'MC 101.70 0040-000 $135.00
,T N0 NIOTION FEE •. 3tiiWD 10 0-000-241-000 $$.20
G1eAI3IIvTt} ti'f'E 101-000-423^000 $10,00
1WR ATT1T1 T(I_Il Rfi FEE }` 22S-4)0-443-342
P11=R SE, P1. A14 1.01-U00-4141-34.5 �2S,00
SUB -TOTAL CONSSTkUCTIONI'AN;D PLAN CHECI
�3,15Q.0�
LESS PRE -PAID F73PS
_WO.00
; `. WiAL PERMIT FEES DUE VOW
$2,000.08
D
OCT 10 1995 ' TOT AL PR03�XXT PEAMITrrms
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs p S
Underground Ducts
Forms & Footings %(i f
Ducts
Slab Grade U
Return Air
Steel p
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 p
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection p
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
�Itility Notice (Perm)
DESERT SANDS UNIFIED SCHOOL DISTRICT
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
Date 10/5/95 1 Type of Permit La Quinta
No. 13747 Permit #
Log
Owner Name J. Cox
No. 51-760 Street Ave. Navarro
City La Quinta Zip 92253 Study Area 1113
APN # 773-184-001 Tract # Lot # 0 Square Footage 11257
'Type of Development Single Family Residence No. of units 0
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 1.72 x 1257 or $ 2,162.04 have been paid to D.S.U.S.D. 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 - William J. Cox & Sons Telephone 251-3780-
Name on the check
By Dolores A. Ballesteros ' M rr'R
Superintendent
Fee collecte /exem ted b Ellen Patino �� 'C , F r.
P
Payment Received
Signatur (� $2,162.04 Check No. 5100
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 -
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110M a11b afe t,!�itult
This Certificate issued pursuant to the requirements of Section 306 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 following:
BUILDING .ADDRESS 51-760 "Avenida Navarro
Use Classification Single Family Dwelling Bldg. Permit No. 9510-015
Group R-3 Type Construction. VN Fire Zone Use Zone 'SR
Owner of Building J COX Address P. O. BOX
Palm Desert CA. 92261 By;
City .Daniel P. Crawford Jr. `
i
� to _ Date; February 1, 1996,'.
Building Official
POST IN A OONSIICUOUS PLACE