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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
9 to Signature of Contractor
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
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. N
(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
q'de, I shall forthwith comply with those provisions.
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# CONTROL#
9904-085
DATE VALUATION - .78(,g�� LOT
S ; TRACT 3� �9 Q
JOB ADDRESS .41-.�,t241.kVENLDE�r.ARRAll�iZ�4.
APN t7.;Y��Y�^�A� •
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JACK v1,ARK A
J'."COM::i.A.TtK trF ERA , C'Ox!'"MACIT.".R'..
-
LA Q`:Jll`P'`M C A 142253
USE OF PERMIT
r
si•.iJ - 't'ji.Am1 ! ti,J � jNCILWL B.1..00K WftLU.',
(YR .4J4. 1. f
MPT 2.•91999 11;
f Uki't:I4/s`at�t(y� 195.rN.► 4F
(3M41OWC,li).Fk10RA' 402.01) Sf?
4't f.+"i'. WOCN) FLTi,4 i3" 2:fr0o L
S:CDNS'I'.ttOCICK1.141FOs )tJ.y.-000-418.0w)
4'r .:WF;.{1t:CK 1•'i 3
4MW1 FIX..
PL'U'MFil N0* FEE t 01-000-419.0(110
$10.50
s%to*110w.i+3'r itf:14 101-()Q()-241-000
'1411
Cj1SrS14.tlif� 1,:t1% i.Cl1-tail-=t73 t)Utf
�20.i►e
►�+fr)�,A.1'Tlti)C,`I`r.titd� itl�J� Z:2:`�-17i�.r#�iJ-'��32
$3.d3i.U�
PRF;011H.PLAN 1f).1-NO0 441,.345
�ARJ I)v PIJfC1K P►,;tCUL9 ,. Rr!?A 1; 701-000-255-000
' 10697
1')13 sya::yG,°lt)" 1�l t3f3�i.139'li3
4250.00
x; 5,2114
tlnryya�{. wf 1!�•��(yt("� HECy+r►�`.y
J16
SIS FEES
')l'(i"6'A3, 1W.10; .ii OAV 54,954.16
RECEIPT
DATE
BY j tt
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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
0. K. to Wrap p;u4j
F.A.U.
Framing s
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 fl
Final
Final _3 v
BLOCKWALL APPROVALS
POOLS - SPAS
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL LCA
ti
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
I
i
Final p
Utility Notice (Perm)
COMMENTS:
I
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 5/29/98
No. 17097
Owner NameJack Clark Jr.
APN # 773-061-010
Jurisdiction La Quinta
Permit #
No. 51-220 Street Avenida Carranza
city La Quinta zip 92253
Tract #
Type of Development
Comments
Lot #
Single Family Residence
Log #
Study Area
Square Footage 2,396
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 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
1.93 X 2,396 or $ 4,624.28 the property listed above and that. building
.Y J�•
permits and/or Certificates of Occupancy for this square footage in this proposed projeEtmay, now be issued
r,
Fees Paid By Cashier CheckNalley Indepdent Bank/Jack Clark TeleprAnP
Name on the check
By Dr. Doris Wilson
rf z r
Superintendent
Fee collected /exempted by Juanita Green . Payment Received $4,624.28
Check No. 166107
Signature
NOTICE: Pursuant of Assembly BjK3081 (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
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CITY OF LA QUINTA
SUB -LIST
CONTRACTOR -�aJI- ClA-v1L0 Jv. ADDRESS 5q3rn-0 Ave.
OWNER JOB ADDRESS VAY'JoL 5
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors t
are on this list are the same persons performing the work. Any changes to this list must be approved
City of La Quinta Department of Building & Safety Drior to work being performed by • a changed s
contractor. Failure to comply will result in a stoppage of work and/or the. voidance of building permi
TRADE
SUB -CONTRACTOR'S
NAME
TYPE OF
LICENSE
STATE
CONTRACTOR'S ::
LICENSE: :::. .::.
NUMBER
WORKER'S
COMP. NAME/
NUMBER ON FILE
CITY
BUSINESS
LICENSE
NUMBER/
EXP. DATE
GRADE/
EXCAVATE
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