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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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
1 -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'
( ) I am exempt under Section , B&RC. for,this reason
Date .5 '/ l`' rte.• Signature of Own ereY t�At,e''r
WORKER'S COMPENSATION DEC L' RATION
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.
( ) 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:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(v)'rl 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 Section 3700 of the Labor
Code, I shall forthwith comply with those provisions
Date:�' f � Applicant -,5
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 authorize representatives of this City to enter upon -
the above-mentioned property
� for inspection purposes.
OP
Signature (Owner/Agent) ;'r/ r�!� Date -2' 4
BUILDINGPERMIT
PERMIT#
CONTROL#
DATE VALUATION
LOT ssys-al TRACT
7641
JOB SITE
APN
ADDRESS
79-172S , . i. :B' PLACEti
- a:-iiII1K
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MIKE CLAYTON
OWNER/ BUILDER
79175 A.S14LEY PL
LA QU1 I TA
CA 92253
CBL#
USE OF PERMIT
RPA d
G
CCliv"VIRT'iT1i1RD BAY c^,IT- GARAGE TO 249 S.F. HOBBY ROON4.
BONUS ROOM
:49.00 SF
' 'TIINIATED COST OF CONSTRUCTION
l6.�i�if1.341
PERMIT FEE -SUMMARY
P1..AN CHECK FEE
101-000-439-318 $70.20
C.:ONSTRUCTIONFEE
101-000418-000 $108.00
MECHAMCAL FEE
101-000=421-000 $21.50
ELECTRICJaL SE
101-000-420-000 $79.00
PLUMBING FEE
101-004.419-000 $27.00
STR(WO MOTION:EEE - RE;SID 101-000-241-000 $.s6
cb
~!a
Ob cj
S.
ZSLr.B )TAL CONS RUC ION AND PLAN CHECK
X251 ;f,
�Q
LESS PRE-PAWFEES
U.(,`t)
0�
TOTAL -PERMIT FEES DUE NOW
$259.Sg
RECEIPT
DATE
BY
DPT I AL
INSPECTOR
;�`K
y" ,
d,
pG
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing �a --
Compressor
_
Insulation —e2Q — Q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final /
BLOCKWALL APPROVALS
Final
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
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
d
Final
Utility Notice (Perm)
COMMENTS:
,cvTaeE r,4S € &16'C tl.lE RUAI vivc�62
m K Sr. CdF4S TF -y7- o e
`7
'
. . . .. ..........
:7 a
City of La Quinta
..........
Building 81 Safety Division
P.'O. Box 1.504
8
78-495 Calle Tampico
.... .... ...
LaQuinta, CA 92253
Building Permit Application Tracking Sheet
and
Project Address:o 7 F/
PZ
Owner's Name:
A. P. Number:
0
Address: •-7 o�61-611 10L
Legal Description:
City,ST, Zip: A /,Y eaLl,;v��M
Contractor: 04el',Me�;�Z
Tel WO —779fl�l
.. ........... . . . . . . . . . . . . . . .
Address:
Project Description:*
City.ST, Zip:
Telephone:
...............
..................
..............
. ..............
State Lic.
City Lic. #:
Arch.. Engr., Designer:
Address:
City, ST. Zip:
telephone:
.........
....................
.
.....
Construction Type: Occupancy:
State Lic. #:
.............
.... . . .....
Project type (circle one): New Add'n Alter Repair Demo
Name.of'Contact Person: s
f CG
OSq.
Ft.: ") -Aq
I# Stories:
# Units:
Telephone # of Contact Person: t.
q/ R 94-
EstimatedValue of Project: 0 /iW
�Ml
Mlles
�IWW
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
!ST FL.
2ND FL.
POR
GAR.
CAR P
WALL
ESTIMATED CONSTRUCTION
Su FT t 3
UNITS
ROUtH PLUMB.
SO. FT. .4
Y
ARD SPKLR SYSTEM
SO. FT a MOBILEHOME SVC.
BAP SINK
SO FT. •4 POWER OUTLET
ROOF DRAINS
j0 FT t
DRAINAGE PIPING
SO FT %t
DRINKING FOUNTAIN
50 rT. g
URINAL
VALUATION S
WATER PIPING
NOTE: Not to oe usea as prooeny :az +al.atlon
TEMP. POLE
FLOOR DRAIN
MECHANICAL FEES
GROUT
NATER SOFTENER
VENT SYSTEM FAN EVARCOOL HOOD
SIGN
WASH ERIAUTOp01SH1
APPLIANCE DRYER
WATER SYSTEM
.
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
"
LAUNDRYTRAY
AIR HANDLING UNIT CFM
VENTILATION
KITCHEN SINK.
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE. TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. :g c
BATH TUB
SO. FT. c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID a I+a c
SEWAGE DISPOSAL
SO.FT.GAR a >.c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING A AIR COND. SOLAR
SETBACK
GROUND PLUMBING'
UNDERGROUND
A.C. UNIT '
COLL AREA
SLAB GRADE
ROUtH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPIEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM c
WATER SYSTEM
.
FINAL INSP.
FINAL INSP.
GRADING
��cu. yd,
S plus xf
REMARKS
=S
LUMBER GR.
FRAMING
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
. t
GAR. FIREWALL
LATHING
MESH
INSULATIOWSOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FFNCF PINAL
INSPECTOR'S SIONATURESIINITIALS
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 5/19/98
No. 17049
Owner NameMike Clayton
No. 79-175 Street Ashley Place
City La Quinta
Tract # .
Type of Development
Comments
Lot #
APN # 604-061-005
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area
Square Footage 249
Residential Addition No. of Units
Convert third ay ot garage into an hobby room
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 249 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 N/A
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected/ex pted by Elle Patino Exempt
Check No
Signature
Telephone 779=41'84.
` l f
l �
$0:00-
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 dale 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
bllecl 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