9705-030 (SFD)C/)
H
N C/)
W
O Z) M
N C) LO
T
W �
O �
w Lu CO
I— o_
U)
Z
t 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 fII force and effect.
License #Lic. CI Exp. Date
42. i3xk1 1i 7131
\two
Date r Signature of Contractorzs',
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.
X) 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:
Canner S'PA'CE FUND Policy No. 123"W%
(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 anner so as to become�ubject to the
workers' compensation laws�of Calif nia, ,g�,nn�d agree that if. Istlould •b`come
subject to �a ``�orkers' com eppsation 11ovis'o?is of Section 3700 of the bor
Zode. I�sh�Il►f IhAWith compo v " Kw Dro ions. �
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\aut `orize `representatives of this City to enter upon
the above-mentioned properly r ins eco�
ti purposes.
/Signature (Owner/Agent) Date
UILDING PERMIT PERMIT97�0� CONTSOL#
(P/k_m�SQ.843.30 C
'.JOB
DATEVALUATION LOT TRACT I •�C . t 1
SITE S2-66;1 AVM IDA (.ARRANZk
APN 773485-021
!ADDRESS
WNER
CONTRACTOR/DESIGNER/ENGINEER
DAVID ROS'S MILLER
PACIFIC' TRADES
LA QI_11N'l'A (.'A 42251
fhl0lgt+4-077; C[i1.;t! 1"5
USE OF PERMIT
+Lr -1'tt Mi 1 IA*-% N(.4 1WL0L* 1411.0x;k WALLS OR P100L
"Cf�lAi.'7' CYyN37iiULTTCiN 1.d33.(►0 SF'
GAf1A>t WCAbUft JIK1 521.00 S6'
6 F3'. W(X)D FbW16 220.00 LF
1.70 &F.
AK' -- Ri3.fii1i711O1't'TAL 1.00 W
MMATZD C''0" CW
""M
i'tr�Mlr ir'it:i1� �i11�I1kSAK�
(()NSTRI X- Tt)iJ FFM 10 l -000-41 R-000 S'14419
PCAN(14RX Fh'f? 11014WAV-118 tw41.45
i&"IAM1CAL FIA-: l Ol •000-421-000 W 00
N.1A IVY'AL PEE 1014)00-4204)00 StO9.(14
1nA %ffiTW) FHR 101-000-419-000 s i 713 5+►
8714NO M(Yn()N FiT? - RYSID 101-(113)-241.000 14E.9iIt
ORAU1NG FFE 101-000-423-000 $23.00
-
ltrw'1t�4`I'11ZUC:1'R112Eht:h 225-000-443-342 $1.9119.31
PRW,'I, 'MAN 101-I(M-441-345 S23c )
St (P-114TA 1 +'()N9f RI u" Tl()N .ANT') PLAN ('NF('K
51.464) 7R
LESS PRE. -PAID FEES
•52.50 00
1'01 All, PFR M17' MERS 01111 NOW
S.3,t19.7Tt
r
'�✓�%
RECEIPT ��
DAT��f '';
BY
DArE/FINALED
INSPECTOR
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
F.A.U.
Framing 7 ^-z I - Cal
Compressor
Insulation L1 —di -1it
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath _ y
Final
Final
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
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:
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/4/97
No. 15592 Jurisdiction La Quinta
Owner Name David Ross Miller
No. 52665. Street Avenida Carranza
APN # 773-285-021
City La Quinta
zip 92253
Permit #
Log #
Study Area 112
Tract # Lot # Square Footage 1432
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
1.84 X 1,432 or $ 2,634.88 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/Capital Bank of North County/Miller #40796 -Telephone 564-0273
Name on the check
By Dr. Doris Wilson �-
Superintendent
1
Fee collected /exempted by Pauline Pearson Payment Received $2;634.88
Check No. 047548
Signature Q A.4 LAA 1 pf(1 AA AA Pym
40TICE: 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 permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
;ollect 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
COACHELLA VALLEY WATER DISTRICT
Received From:,
Address:
Account No.
Service Address
G.A. Code
�"rvice(s)�rf S O • 9!V CJ
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
(Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt. E
❑ Customer Deposit
❑ Other
' TOTAL
Remarks: ��yi-� +✓ -�1�� _eg
❑Copy to:
Cash Water Service �''✓-d
Check
Money Cashier
Order
Tr
�M1
CVWD-438 (11189)