9607-045 (AR)LICENSED CONTRACTOR DECLARATION PERMIT# CONTROL#
O7 I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 9607-041% 3710
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
N W Professionals Code, and my License is in full force and effect. 7/16/96 fit, 68,410
O ::) Ch License # Lic. Class Exp. Date
P� d In JOB SITE APN
r�. Lu ADDRESS 53-380 &VENI0A QfiJTWINM 774-OXI-026
Z N Date Signature of Contractor OWNER CONTRACTOR /DESIGNER /ENGINEER
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J U � OWNER -BUILDER DECLARATION MICHAEL ROSENFELD O�3INER-BWLD ?1.
1-- W I hereby affirm under penalty of perjury that I am exempt from the Contractor's -1.33I30 AVENIDA CARKANZA
U) License Law for the following reason: LA QUINTA CA 9'224'3
Z_ ( ) I, as owner of the property, or my employees with wages as their sole {ryRI.ft
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals 1tlitij!)t N'I'1A1. AI)Di t ulv
Code).
M () I am exempt under Section B&P.C. for this reason F -M -71.051x),18 SQ1IARE FOOT PATIO IN TO LAIJNDRY ROOM
N Date Signature of Owner
ON
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U Q WORKER'S COMPENSATION DECLARATION
12-
Z V/1L#!rt'11��N t,9Gl3.ttt► 1.S
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q V ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Z permit is issued. My workers' compensation insurance carrier & policy no. are: 1(1;STI NINV D COST OI"' CONSTRUC''110N i,91►8.01i
Cartier Policy No.
w ;�!?Kl191'i' !+'F 1♦a Kt1MMAitY
r` O PLAN G• 011C,K FFF 101-000-439-:311{
Q (This section need not be completed if the permit valuation is for $100.00 or less).
CUNS!'RLic'I'Ii�NIf7's
() I certify that in the performance of the work for which this permit is issued, 101.000418.000 $45.0)
I shall not employ any person in any manner so as to become subject to the Mi7.{11ANICA}, 1r1471 101 -OW -1121-000 S15.iA
workers' compensation laws of California, and agree that if I should become 1:IIWi II'RICAI. FIER 101 -C!{1{► -42044 $16,69
subject to the workers' compensation provisions of Section 3700 of the Labor PIA f} MING FER 101-000-4104)(1 VIA%)
Code, I shall forthwith comply with those provisions. I
!3TC �Tk} MSM°I{tihf F1's}3 :}i:itl7 101 -WO -211I-000 S.�UCN
Date: Applicant 04
14
Warning: Failure to secure Workers' Compensation coverage is unlawful and Q( J
shall subject an employer to criminal penalties and civil fines up to $100,000, in l
addition to the cost of compensation, damages as provided for in Section 3706
r 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 SUB IX) TAL CONS"f tUC 10N AND PIAN CHECK
whose request and for whose benefit work is performed under or pursuant to USS I'1tI PA}i> 1v1:IsS ${} {IO
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 Tf)'1'eki, PERMITRMS DUK NOW $127.43
work isnot 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.
(\ RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) Date
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Notice:
Document Cannot Be Duplicated
Date 7/22/96
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 774-081-026
No. 14719 Jurisdiction La Quinta
Owner Name Michael Rosenfeld
No. 53380 Street Avenida Carranza
City La Quinta zip 92253
Tract #
Type of Development
Comments
Lot #
Residential Addition
nc ose patio tor laundry room
Permit #
Log #
Study Area 111
Square Footage 48
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:
RESIDENTIAL ADDITION 500 SQ. FT. OR LESS
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 0.00 X 48 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 B/A > Telephone 564-1011
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson Exempt $0.00
Check No. N/A
Signature PW
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