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! LICENSED CONTRACTOR DECLARATION
A hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9ll(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
ooO 31 C:tOC19 k310�1
Date 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). r /t
(„)Tam exem t under Section B&P.O.,fo� this reason t
Date ! �� L' Signature of Owner I� t
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.
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.
STAIT,a0TxrD
j �,:... 12f. Irl
(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' compensatiomprovisions of Section 3700 of the Labor
Code, I sll�all forthwith comply with.�thoa provisions.,
Date: (( ' Applicant—A 1 1 A T) .be<10, =1
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, inde6nify
& hold harmless the City of La Quinta, its officers, agents and employeds.
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 hi
s City to enter upon,
the above-mentioned property for inspection purposes.
�
gnature (Owner/Agent) S � Date rit L� {qb,
BUILDING PERMIT PERMITN
DATE moigs VALUATION
$11,294.40 LOT TRACT
�
JOB SITE ADDRESS 7�i-�y!jr� t� �+�l1iJM �..1�.� :;r°�1.�1.A�.
APN *77/3-311-��}r'ti
OWNER
CONTRACTOR / DESIGNER /ENGINEER
HA LAN GIiOI'i\III
.
tt%V;XR4D St:rK
Pi HO'K 8,57
82-231 Fst\SU I-111.tt; Cl*.
LA.Q1f!i'TtA CA 42253
INDiO CA
(019)34 / OV99 �„t'"
ttsi:'ky01
t.ef' 3225
�3Z /I7
USE OF PERMIT
ADON
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ri).9IATIoN Nt 3.4111 „1�
ENTIMA`;`S D i:ONT Or WNS'112e CF110N
a I.294' .414
PLAN CHECK Mils' 10!•fX)U-A1l39-3111 &N7 '4
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LESS .lits TAID !'t:l:.;
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,�`;j�'
RECEIPT i.j'
DATE
BY
DATE FINALED
INSPECTOR
m �
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs A r
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
Compressor
Insulation 11A
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
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
�F
Final 2 Q
Utility Notice (Perm)
COMMENTS:
City of La Cluinta
;
Buitd in 8i'Safe D vision
P.O. Box 1504
e.
78-495 Calle Tampico.
P
La Q Uinta CA 92253
.::.::>::::><:::
_ ..........
Building Permit Application and Tracking Sheet
Project Address: 52.- 895
VG C,A�ReAN7A Owner's Name: a
,
.. —6p51 ,-r TIT
A. P. Number:
Address: 59-895- ` y a Z
Legal Description:
'ty,ST, Zip: LaQu i 64a 'C
Contractor:5to
1�1
Telephone: -
Address: Z-a Lt
Pro' c Description: 468 ' O (ply co-L- PkkDt-,L.
Ciry.ST, Zip: y
AO / O
n
TeleP o D-
XXh
State Lic. # : o Y
City Lic..#:
Arch., En_r., Designer:
Address:
daft 6S0 CAL 4LL W CvR ISS
City. ST. Zip:
X 71,%p
t ho ne:
TeeP
anc
Construction Type: Occupancy
YP Y
State L c
r
Projcircle one): New Add'n Alter Re at Demo
..................................................... Project b'Pa P
Name of Contact Person:
Sq. Ft.: �
# Stories:
# Units:
Telephone # of Contact Person:
- Q $ Estimated Value of Project: �
<`. < APR6ICN....
::::............................T.......Q..I
C.................�lA........IS..4............................................................................................
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING dPES
1$T FL SU FT- 7t S
UNITS
r . A.C. UNIT
COLL AREA
SLAB GRADE
ROUGH PLUMB
YARD SPKLR SYSTEM-
2ND FL. SO. FT. g.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOSILEHOME SVC.
ROUGH WIRING
BAP SINK ,
POR. SO FT ui
ROCK STORAGE
FOUND, REINF.
GAR SO FT. 4
POWER OUTLET
ROOF DRAINS
CAR P SO. FT 4
REINF. STEEL
DRAINAGE PIPING
WALL SO FT %L
DRINKING FOUNTAIN
SO cT. g
WATER NEATER t
URINAL
ESTIMATED CONSTRUCTION VALUATION. S
FINAL INSP.
_ WATER PIPING
NOTE: Net to be used as prooeny !ax +a aatton L 4
r
FLOOR DRAIN
MECHANICAL•FEES h
,
LUMBER GR.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
FINAL INSP.
WASHER(AUTO)t01SHl
APPLIANCE 'DRYER
r
;
1
iW
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GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR • SUSPENDED
*�—
t
. �. LAUNDRY TRAY
AIR HANDLING UNIT CFM
r o
i i
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE. TEMIPERM
�� LAVATORY
HFAT;NG SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. c
LATHING
; BATH.'TUB
SO. FT. c
�.
WATER HEATER
MAX. HEATER OUTPUT. B.T.U.
SO. FT. RESIO ry I?p c
INSULATIONSOUND
SEWAGE DISPOSAL
_
SO.FT.GAR @ 4c
HOUSE SEWER
'
FIMAL INSPECTION
GAS PIPING.
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES •MICRO
FEE, ' • •
MECH.FEE .• PL.CK.FEE
CONST. FEE
JELfECT.EE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL - HEATING III AIR GOND. SOLAR
SETBACK
GROUND PLUMBING' ='
UNDERGROUND
ro �' r
r . A.C. UNIT
COLL AREA
SLAB GRADE
ROUGH PLUMB
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCTWORK
ROCK STORAGE
FOUND, REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINA4 .
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL) � #
TEMP. POLE
GROUT
WATER NEATER t
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. y0.
,
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
;
1
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'' — ♦: Vii' i
i r .�` .! ..., i ;.
i , t ,. `,� .•.r +
REMARK&
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
�.
MESH
ter'
INSULATIONSOUND
_
FINISH GRADING
FIMAL INSPECTION
CER . OCC.
cc.t c SIIJ�1
SIGNATURaw"MALS
GARDEN WALL FINAL
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/1/98
No. 17100
Owner NameHarlan G. Bosler III
No, 52-895
City La Quinta
Tract #
Street Avenida Carranza
Lot #
APN # 773-321-008
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Square Footage 208
Type of Development Residential Addition No. of Units 1
Comments
Addition of 208 sq. ft. to existing construction.
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 208 or $ 0.00 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 Ana Bosler sT
elephone,"
Name on the check r
By Dr. Doris Wilson
Superintendent ' i
s . .
Fee collected /exempted by Juanita Green Exempt $0.00
_ Check No. N/A
Signature omG�/ A
NOTICE: Pursuant of Afembly 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
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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