SFD (0108-330)j LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
hapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
'"License J1 Lic. Class Exp. Date
r
f 291728 B SA ZZ�Fa l i
pate7�,' • f`y f Signature of Contractor
1✓ �r %
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).
( ) 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
Se tion 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.
STATE TNAT) 229-91 iTlr IT 00403
(This section need not be completed if the permit valuation is for $100.00_%, 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 /'"� f� 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 okuuarOLOID
his
application.
1. Each person upon whose behalf this application is made & Ben at
whose request and for whose benefit work is performed under oany permit issued as a result of this applicaton agrees to, & sh i de
& hold harmless the City of La Quinta, its officers, agents an em to ees.
2. Any permit issued as a result of this application becomes n II and v®di V OF
work is not commenced within 180 days from date of issuahce of suEONAF
permit, or cessation of work for 180 days will subject permit to cancellation.
r 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 propery-fo inspection,purposes. i.
!S gnature (Owner/Age P) .-�Yr�G,"°'` "" ""'r Date
BUILDING PERMIT PERMIT#
DATE f VALUATIONLOT () ffla.�'V TRACT
IM '173'16 19
JOB SITE r °
APN
ADDRESS
51.400 ,A :R)DA. RAV.41Z#.?..O
7113- . 0W
OWNER
CONTRACTOR / DESIGNER / EN (NEER
P0 BOX 3.1578
46900 JACK30,1 By
PA'1.1a D1:1B%R11' CA 92261
TMWAAL CA, 5�2,,27 4
���
C160)399-1.20 �y'. gLO '4954
USE OF PERMIT
3NfiYtO-Ai
%d YY.l':►aArS.3^I i.:f
3.1171).P1?rrMIT DOFS'NOT MC;LUM, B1-,0i,iA'"WA1.1.,.!; PC ,_1J`;iPA OR
DRhrliWJ',%Y Al'PROA.CK
QMWITC9C.1}.RPOR.T maxq w.,
PORC''WPATIO 36.80 Sly
TRACT Ct7A1S'€li.ifC.002E 1ym 1,00 VF
ERIMATED COST OF CONSYRUCROIN
83,=4.70
:sem"Alf€ VXX Sri GARY
FE 1;'tPa;+SI T 103-000-439-318 42M.00
C.` d: 3Nf3'i�tt3S::"{'.iC,11"Qr 101-000-418-000 $56750
MECRAMICAL FF.S 101-000-421-000 S3330
9pr�..t�VIVII'CAc Z
11t�sa,xdaN000-4:9,i0-l0�00 �$pl106.t011
7
VP
Pbal7l3l.F3AarO M'P_F 90f'"1300-4 9-000 PYAli2iA
=0140 f OTIGH IMF? - i7,PSID 101-000-2414 -000 0.5a
c3R44.DINO P 101 -ON -423-000 VEIN
;
PSsi?Cl l? lal.AIJ 101--000-441L345
i3k^'.e1s1.O11 ER IMPACTME�1,9t+'i.ti0
1?1,pal r.,'lircl mr. a 1101-000439-318 1473.E
v.
2 4 2001 ` IEst- TAL Cqn� ffl'R[ ��.�Kr%Y~r AND PTAH' CUECK
'SS
��,���..0:�
TYRE -per )IMS
,.V45D�00
LA QUINTA
CE DEPT. TOTAL Tye"Rs(iUTT7.CES DUE NOW
6 <i►l
RECEIPT
DATE
�Y'
DATE F 9�E O
INSPECTOR
Buildin
Address
Owner _
..fAc� +I�,-r•+�v+r»* ;���yr+�a...�;;ryS�..%�3,;� � -�" 7� ti,,"'LS;rT�r•�r..,
4P.O. BOX 1504 -- APPLIC ION ONLY
78-495 CALLE TAMPICO c�+
Nava rrn LA QUINTA, CALIFORNIA 92253
0`
3UILDING: TYPE_CONST,'. OCC. GRP.
\.P. Number 77 W/� 7 CO
Address �Q Vx 5'�-�
City_Jr,Zip Tel.
Contractor
tY Zip
State Lic.I City
& Classif. Lic. N
Arch., Engr., 7/, Il
Designer V PfN e? T
Address Tel.
CityI Zip I State
Lic. If
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason; (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish• or repair any structure, prior to 'Its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 Dy 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
1-! 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, Buisness and
Professions Code: The Contractor's License' Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such linprovements are not intended or 6Jferad for sale.,,lf, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.) j
I -I I.
as owner of the property, am exclusively contracting with licensed contractors�to con.
struct the project. (Sec. 7044, Business and Professions Code: The. Contractor's License, Law
does not apply to an owner of property who builds or improves thereon• and who contracts' for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
i ] 1 am exempt under Sec. B. ii P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
Policy No. Company
F1 Copy is filed with the city. ❑ Certified copy is hereby furnished.
�svgAL ;�
CERTIFICATE OF\EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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. +•
Date Owner `
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the workers' Compensation provisions of the Labor Cotle, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days. I
I certify that I have read this application and state that the above information is correct.
1 agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
_ Signature of a0plicant Date
Mailing Address
City, State, Zip
.egal Description L4 is Rik /-;?/ / / KJ( KAo
rroject Description Y) ^J i' 4Atr+rl L, �1 we.1 firC
IIJ _11
., /L- lc./., Af t� ;,?,YAfI/A /s - �!
Sq. Ft./_Soo
Size i
No. Dw.
Units
Add ❑ Altdr ❑ Repair ❑ Demolition ❑
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from"Property'L-ine--- • p
I t rr ti � I
FINAL DATE INSPECTOR
Issued by: Date ' Permit
Validated by: Aur, — P 2001
Validation: 11
WHITE = FINANCE ! YELLOW = APPLICANT PINK = BUILDING DIVISION
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from"Property'L-ine--- • p
I t rr ti � I
FINAL DATE INSPECTOR
Issued by: Date ' Permit
Validated by: Aur, — P 2001
Validation: 11
WHITE = FINANCE ! YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: - La Quinta, CA 92253 r
Document Cannot Be Duplicated 760-771-8515 `
CERTIFICATE OF COMPLIANCE
Date 9/24/01 1 APN# 773-184-006
No. 22529 Jurisdiction La Quinta
Owner NameMountain Cove Development Permit #0108-330
No, 51-870 Street Avenida Navarro Log #
city La Quinta Zip 92253 Study Area
Tract # BLK 121 Lot # 19 Square Footage 1347
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
2.05 X 1,347 or $. 2,761.35
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 B CC / Canyon National Bank - Rose Schafer l''`am .,
Y Y Telephone. 760-771-1670
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exem ted by Annette Barlow
Payment Received $2 61J3,5'
-�
Check No. 07474
Signature
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
bove 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 Distdct(s) or to another public entity authorized to
3Ilect 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:
F-mbossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 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: 51-870 AVENIDA NAVARRO
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0108-330
Occupancy Group: R -3,U-1 Type of Construction: VN Land Use Zone: RC
Owner of Building: MOUNTAIN COVE DEVELOPMENT Address: PO BOX 3578
Building Official
City: PALM DESERT CA 92261
By: KIRK KIRKLAND
Date: 01/08/2002 -
POST IN A CONSPICUOUS PLACE