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9909-213 (SFD)LICENSED CONTRACTOR DECLARATION . ' - I hereby affirm'under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Divisioh 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Pate 5317333 AS M112 Oate Signature of Contract r OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: (. ) 1,.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). ( ) 1, as owner of the property, am exclusively contractind with licensed contractors to 6onstruct the project .(Sec. 7044, Business & Professionals Code). I am exempf under Section reason B&P.C. for this 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 certi.ficato of consent to self-inqure 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 issue d. 1�y workers' compensation insurance carrier,& policy. no. are: carrier Policy No. STA"173 F M110 (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 s . o as to become subject to the worker " compensation laws ' of California, and agree that if I should become subill, Cto the workers! compensation provisions- of Section 3700 of the Labor .de, I shalliforthwith comolywitli7K6-se provisic'ns. ,ate:I', ifl I Applicant— Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil� fines up to.$1 00,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Applicat ' ion is hereby made to the Director of Building and Safety for a permit subject to the conditions and Yestrictions 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 thi ' s applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a resulf 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 constructloh', and hereby authorize representatives of this City to enter upon the a . ve-mentioned property for inspection purposes. 1p", 11. 16 _1 /inature lOwner/Anent) Date Ili - ),Hot PERMIT# SUILDING PERMIT DATE VALUATION LOT TRACT BJ,K17,1MJj20 JOB SITEJ AD AVENW& CAM UNNZA APN 774-24.1-011 .54-480 OWNER CONTRACTOR DESIGNER ENGINEER Noon P.O.K)X UY758 P.O.. DOX 10,758 PALM DESE.Wr CA 92M-07 53 PALSI DISSERT CA T,1255�07' ?-s2( ) USE OF PERMIT SR4'�U-, FWD .. IOU @ 0 i8j.T 4',GARDEN 13DXK WALL PERIWT-DOES N(Y4'MLVJDL1 POOL TR ACTCONSITRU 'Uvi-4 CiN 0.110"IM 3F PORMPATIO W1.q(1 Sir 5.44'r. WALL FT, WALL 18.0 LF 5 FIF, WOOD FEINV11 17%,0011P 0 S TE A '11 W11 ty S .0211TONISUR clrfa�x ffl%lk Dcolff t PERNUT MEE SIA-I&I.Ally C-ONSIRVICTION f%E4 104-000�418-0(k 'Pf, AN QW,rK YFF XW(,T;A'N[Ji7A1. F EM, �000 S60,00 h LE C Ild C A Lv�c,.z 0 i - (KO, 420-000 101 -4)00-421�000 i D0V F, I � 0 1`1 U, R, 10v &AX -,f F Fk, PJRW'13F� PLAN S19)00). M I q - TV I �.A C I N",31 R I U n 0 IN A. N D P 1, -A N' r, t m., K. L.E,135 PRE-PIVE)FEES V50,00 I'M Alk,PERM-ff FEEN DUK'NOIN RECEIPT DATE By DATE FINAL ED INSPECTOR INSPECTION RECORD OPERATION I DATE I INSPECTOR OPERATION - I DATE I INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Forms & Footings Underground Ducts Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans 0. 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 -!57 _A.Y Final I Final POOLS -SPAS BLOCKWALL P OVAL9 Steel Set Backs Electric Bond Footings 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 12- 1 - Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final M7 Utility Notice (Gas) ELECTRICAL A ALS VPROV 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 &-z Utility Notice (Perm) 3rz. 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 54-480 AVENIDA CARRANZA Type of Construction: VN Owner of Building: MUMBIL, INC. Building Official Bldg. Permit No.: 9909-213 Land Use Zone: RC Address: P.O. BOX 10758 City: PALM DESERT, By: STEVE TRAXEL Date: 03-21-00 POST IN A CONSPICUOUS PLACE CA 92255 Notice: Document Cannot Be Duplicated Date 10/19/99 No. 19483 Owner NameMumbil, Inc. Desert Sands Unified School District 47-950 Dune Palms Road La Quinta, CA 92253 760-771-8515 CERTIFICATE OF COMPLIANCE APN # 774-243-011 Jurisdiction La Ouinta No. 54-480 Street Avenida Carranza City La Quinta zip 92253 Tract # BLK288U26 Lot # 13 Square Footage Type of Development Single Family Residence Comments Permit # 9909-213 Log # Study Area 1548 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 1.93 X 1,548 or $ 2,987.64 the property listed above and that building` permits and/or Certificates of Occupancy for this square footage in this proposed project may now"b' a issued Fees Paid By cc/VIB/Mumbil, Inc.Tele—' phone, 340=272..h Name on the check By Dr. Doris Wilson, Superintendent Fee collected /exempted by Juanita Green Payment Received $2,987.64 Check No. 207635 Signature NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9D -day approval period in which you may protest the Tees 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 CHARLES D. GARLAND Architecture, Interiors, Space and Land Planning Structural Calculations 2q sj�!►3e�.. % COM Gt'C`I or L -P+ ao wkTb pV.:©r- ?,OkL0ka(A A LA &Ott"l-TA IAC c SS CALL. /t. AVV i Y -r J t �-� AyF,12 V: t r Vy t= O TW VW SS A LL (,. A'tr O uu S LP H OJ T f YLI�- PA q-l�,.D t a & 'PYA J IF- �a� Ir Ix 1K% V-) 1 -1A -4r TO0nt0 rtt�f N\ To �� ►�ST�v`ITIA�..CD nl►�� iL�nANC.f-= \11l"CK -tKV- Qr-SIi11r� �NZIIN T O►= -CKt= C O IntS Z"C TOON p O C -U Ml= N-C.S. 35-325 Date Palm Drive , Suite 151-J- Cathedral City, CA 92234 - Phone/Fax: (760) 324-7146 Desert Sands Unified School District CERTIFICATION OF PAYMENT OF SCHOOL FACILITY FEES �J TO: City of La Quinta DATE: rO/Y/.v'17 Department of Community Development 78-105 Calle Estado La Quinta, CA 92253 This is to certify that developer of c which is located at // p ,` �' / .S within this DistriA has paid school facility fees imposed pursuant to the authority generated by Government Code Section 53080 in t e amount f covering a total of// //-3 9 square feet of ( r sidential or ( ) industrial/commerl development and that building permits for this footage in this development may now be issued by your jurisdiction, (d �1LOYlZea� y �' •` for DESERT SANDS -UNIFIED SCHOOL DISTRICT /White - Building Department • Yellow - Facilities Planning • Pink - Accounting 49 Gold - Developer 7 e7 (10)-37