9803-073 (RPL)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 J(, Lic. Class Exp. Date
50M67 B 3131 /99
;,Date �` '�r Signature of Contractor t" i;_
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.
ve 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.
EX1;.' v1P11:GN ON FILE -
(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: 3
Date: ;F��r1. �; Applicant.
tl
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth. -on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
t
A Signature (Owner/Agent) �f; ;i d�! - Date' l r
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT 9803-073 TRACT
59,000.00
JOB SITE
APN
ADDRESS
51-733 "E. C'ARIRANZA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JACK CLARK
JACK CLARK GENERAL CONTkAC; VOR
LA QUINTA CA 02253
(760)564-3511 CBL# 1.115
USE OF PERMIT ,rf
P001, ONLY.. NO i ATM, ALAIUMS/E;A WURS .ARF TCS MROPI R XTION AL
PRIOR TO FN-CAPMR&PLASTt, TNSPECTION
r
�%
MAR 1998
POOL Alall7li7.R SPA 9,0130.00 LS
CITY
OF LA QUINT!
f
DI
ESMIA�i C, U—COF CONSTRUCTION
9,000.110
PERMI'1. EEE SUMMARY
P1, AN CHECK FEE 101.-000.439-318 570.20
CONSTRUC"TIONFEE 10,1-1200-41$-000 $108.00
ELECT" UCAL FEE -- POOL 101-000-420-000 $45.00
P1 LI'MI 0 FE -- POOL 10.1-000-419-000 $27,00
�J
SUB-T(fTAL CONS MUMION AND PLAN CHECK
5250126
-3 LESS PRE. -PAID IFTTES
� $0.01)
TOTAL PERMTr FEES DUE NOW
S250.20
RECEIPT
DATEBY
J
DATE FINALED
INSPECTOR
/
�<
vo
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
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
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
�(,�►p
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
s
Final
Utility Notice (Perm)
COMMENTS:
CITY OF LA QUINTA
SUB -LIST
CONTRACTOR JAu'- CLAP-aC_ i,EN. Cmrr—. ADDRESS
OWNER CLAek4- JOB ADDRESS_!S1_1.3-3•Ave Garran2et
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous plac
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors th
are on this list are the same persons performing the work. Any changes to this list must be approved t
City of La Quinta Department of Building & Safety Wia to work being performed by a changed SL
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit
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
A Gm -.s
G Yr-AVOCT, .4r4
A/C -12
(vI00o5
9131149
STari Fvaa
14.43013 •96 .1,/Qq
,9ti7
� 5
PIPELINES
C-34 .
CONCRETE/
FOUNDATIONS
C-8
ASPHALT
A
FRAMING
B
STEEL/
STRUCTURAL
ARc4vL-erA
6•C_4VAf14C4
_G.,5 -r
A
73739'1
(115OA9
CA /0040?e
KOW437A
,�33
MASONRY
C-29
PLUMBINGC1a
LATHING
vMDG
eaG
C-36
C-26
52(¢37
A im 3N'
4731 ' s
DRYWALL
C-9
PLASTERING
/ 44w-671Ac,%
1C_8fA*
73 7 397 0411"80*7
i -Aoi r
37A 419
48ai
HVAC
C-20
ELECTRICAL
{ �wL
C1,c'AAw vm- fwM0 t
e -10r
C, 51.,
5Z/ 4a7I ;r
Ca 10PtW
11 a B
+731 121SIl
ROOFING
C-39
SHEET METAL
C-43
FLOORING
C-15
GLASS/.
GLAZING
C-17
INSULATION
C-2
SEWAGE DISP.
C-42
PAINTING/
DECORATING
C-33
TILE
C-54
CABINETS/
INSTALLATION
C-6
FENCING
C-13
LANDSCAPING
C-27
POOLS
�E1P�iAU Cfi
'�' is
3s9�o5 5
STATE POND
io i
250
�
OTHER
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 11/4/97
No. 16228 Jurisdiction
Owner Name Jack L. Clark Jr.
No. 51733 Street Avenida Carranza
City La Quinta zip 92253
Tract #
Lot # 11
APN # 773-124-023
La Quinta
Permit #
Log #
Study Area
Square Footage 1478
Type of Development Single Family Residence No. of Units 1
t
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
1.84 X 1,478 . or $ 2,719.52 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/La Jolla Bank/Jack Clark ,:Telephone
Name on the check r
By Dr. Doris Wilson
Superintendent A ,
Fee collected /exempted by Pauline Pearson Payment Received
Signature �� Q¢ ALAA_�Onti
Check No.
$2;719.52
301080
VOTICE: Pursuant of Assembly Bill 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 peril for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
milect 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