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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
4 S ct 1. 217 112
Date >_ 1� Signature of Contractor
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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:
O 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:
Cartier Policy No,
4T'.ATS? FUND
1280940-04
(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 Sectieh-3700 of the Labor
Code, I shall forthwith comply wit those provisions:
Date: Applicant
Warning: Failure to secure WorkersCompensation coverag s unlawful and
shall subject an employer to criminal penalties and civil firms up to $100,000, in
addition to the cost of compensation, damages as provided for iri 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. It I
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 4
theabove-mentioned propefty for inspection purposes. r'••
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Signature (Owner/Agent) +"�"" 1 Date
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BUILDING PERMIT PERMIT /J
DATE VALUATION LOT 0012-241 TRACT
PIX: 224 11`1'
JOB SITE
APN
ADDRESS
Ca -WO AWKIDA CwAIRRA ZA.
774.-121
OWNER
CONTRACTOR/DESIGNER/EN (NEER
�DAVMROSS 1Vt1;fZM
PJACT RIC MAL7MS C°t)MSPrA1:rC'17.0W
S oaf "...�....AW"R, CA 920*4
USE OF PERMIT
33��.F• •••.i�,flP:7'-d4.r .ZJJ iH.7el��Yi,J'
S" x'17 ? ERN1.1T DOFX NOT 11410XIDF HL OCK 'WA#1,4 K)O1, A' SPA OR
LAWKWAXAPP ROACH. 98' 1AA9 i KR- %08 CAR00"
TRACT C'0-N3TkUCT10-.q 11SO0.00 SF
PC).€LMPATIO 24.00 SF
L" 1.ARAA3MAh.rPtiRT (SF) 3n05.20
3 Ff. WOOD F04CE 20.00 LIP
PERAWDi"P.,� SITA2MARY
CUNYS'1`R3sG"g' ON FR 101.000-416-000
PLAN CHECK €R8 101-•000-439-13 18
MECHANICAL 1(11-W)0M473.000
St:Y,C TRIC AL nE 101-000-420.000 X11 J.
PLIUMBITY10 FER 101.000.419-000 E11.a.`i3
"P1ZC"Y.40 MOTION FRE - RES10 101-000-241-000 x.35
0RAP31• O PKE 101-000-423-000
[1'041'LOPM 111PACT FEE" �199� 410
PflW'SY � ,A11 101^(3(112-141345
k'1•:9 DEPOSIT 101-000-439.319 •�YSO.iIO
Sf -°t't? `.lir Cf)%iS1RLiCT� ?i AND PLAR C:HECY,
$3,42S.53
two 1) r, .FAA Imp;,
4250,60
11"'TMI P1?:1 i'i': i Mrs ME NOW
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RECEIPT
DATE�%/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
_ _/
�Z,�b C
}
/�
7� c
Underground Ducts
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
2i2, -et
5;7
F.A.U.
Framing
Insulation
Z . o (
=S p(
,*fir
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
_
'�!"-(
S�
Final
_
Final
POOLS -SPAS
BLOCKWALL
I!
APPROVALS
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
Water Piping
Plumbing Top Out
_ _
120
yl
_'
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
2 ��
`
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit l
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)�� �''�
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SFD
Occupancy Group: R 3
53-560 AVENIDA CARRANZA
Bldg. Permit No.: 0012-241
Type of Construction: VN Land Use Zone: RC
Owner of Building: DAVID ROSS MILLER
Building Official
Address: 1719 S. TREMONT
City: S. OCEANSIDE,
By: STEVE TRAXEL
Date: 05-24-01
POST IN A CONSPICUOUS PLACE
CA 92054
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 2/13/01
No. 21647 Jurisdiction
Owner NameDavid Ross Miller
No. 53-560 Street Avenida Carranza
city La Quinta
APN # 774-121-004
La Quinta
Permit # 0012-241
Log #
zip 92253 Study Area
Tract # BLK224U21 Lot # 3 Square Footage 1500
Type of Development Single Family Residence
Comments
*Received overpayment o - issue re un .
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
2.05 X 1,500 or $ 3,075.00 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
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Fees Paid By CC - Capital Bank of North County - J.R. Tel p one
760-805-1251
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow
Signature
Payment Received $3,090.00
Check No. 080324
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
rbove 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
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove Residential)
District, in order to determine the applicability of compatibility issues or need to require the filing of Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as your
correction list. Please attach additional explanations as necessary.
4" U)D Noryle?fO , !/19/0l
APPLICANT PACIFIC TRADES f}-ypeSs
SITE ADDRESS j% 3 S90 AvF cA eQ2 2!4
�?Y- 121-noY l Zoo�39
APN 7-� --U� - 93-5- BIN NO.: Jam' CASE NO.: -2899 369.
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LEGAL: LOT BLOCK -2-24 UNIT _ � S.C.@V.L.Q.
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CHECKED BY: Wally Nesbit DATE: 0
bvsp.. 1/?- 310 /
Inform the assigned Building plan checker upon your assignment to this case. The CDD Executive
Secretary maintains a log book to track applications and assign case numbers. .
REQUIRED ITEM
Y
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COMMENT/CORRECTION
Compatibility Review
N�A ✓
Case logged and number assigned
6`'j3/' nL0 04vc ^oma css i/
Verify legal and APN information
L-A ,sjr��s �'� "'�'�" a 0O-
Consistent with MDG on file (as.applicable
1/
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MDG
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
Colors
Materials
Architecture
vic v�V Mufs do L��.►-nom
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Ofiher-}2�quirements:
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2. Vf-1Z11e-/ .Gar o wrw'f/L.I4 ro
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Case
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unity Dev. Dept.
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