0012-300 (CSCS)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
q� 1
ff 32723115.(.� �'} � 44,9
at'e �� _: Yet Signature of Contractor r °—i�t.rf.t' -�
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:
( ) 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.
(r:) 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:
Carrierp VV//33yy��yy Policy No. xy Ci 1:19-004
(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 Section 3700 of the Labor
Code, I hall forthwith comply wit i hose prole is yns.
Applicant
Date:" J'Yca pp �+ 5d
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 v
application. . I
1. Each person upon whose behalf this application is made*& each person4a.3,
whose request and for whose benefit work is performed under or pursuant'toF;fir
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 stale that the above information is
correct. I agree to comply with all City, and State laws relating, to the building
construction, and hereby auorize representatives, of this City to enter upon.
the above-mentioned prope"rty for inspection purposes. i
> loug., A�'�� Dat �_z _ R}
,Signature (Owner/Agent),.-•- ��"V,
'Signature
7 C-1 7
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (1012.131 M TRACT
JOB SITE
APN
ADDRESS
t;p
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JDD LW
0-1, MURPHY (!0.R;TfkUCPH0H
.50014r-iAN112 UBISTE
A2.764X.W0 A
ISSAQUAH WA 98027
]PAUVI 131MER"r CA92260
(760)340.3423 fel t 05430
USE OF PERMIT
ffO.3>KR+f,•..'{':fAL Ff>E.1ILDIND- !i7'A4 SQUARE PEE -r. BVR P.€No4 OV4
C014lTRj CTAW10LtNT 183,116.16 us
r
riXYn<fQd.d: D R✓�ld'i1iY1 (W 4rwr.Li��diY VC-IAd.T.}1�Y
194,200,96
y�'y; g�r��♦x ung ��Q@y��' �+.�pF11q.
.S'�":Y.U'�I:GAY:3 '. •FW'F: ' l7YJkYTIVAAdi Y
CONSTRUCTION DWI 101 -000-,418-000
PUU4 CHOCK FJf<J::. 1.01 004-439-318 !rA)3.2:a
71B14-7'��'F,iay�,.'��9pJ''T 101-(0�i50-439-3'18 •%t,p0rtt�0+`00
I�.7JCL�YrA+.G::�. Q? 101-00��f0-�r��Ak.I+^'(0�i!/ys0 Wp�i�u>3•�`�0
ppt�s� sv.•�,6�Art
STROq'l�s� ,6 OTION Y:U E — W<</MMI I M)-000—�b'e41 -000 d✓•1'W. !)a
MOTION
QR.AD1HCJ FEE 101-000-423-000 s0.p
DEV;U4143ER IMP -ACT FEE
.&a)IT q4 .P'U.RL9.0 YLr.iC:t!S - CXM? 701-00045 5-000 53i'al.;i0 .
q 4, A
DEC_ 2'9 K0� .,.y ,
9
RECEIPT
;DATE [ BY
DATE FINALED
INSPECTOR
)/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings C/ i �i�
Ducts
Slab Grade l
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.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
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
Final _
Utility Notice (Perm) Cr
COMMENTS:
IfA
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: t , La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 12/13/00
No. 21349 Jurisdiction
Owner NameLa Quinta Court
'No. 78-555 Street Highway 111
City La Quinta zip 92253
Tract #
Type of Development
Comments u -H
Lot #
APN # 643-020-007
La Quinta
Permit #
Log_ #
Study Area
Square Footage 5344
Commercial No. of Units 1
4
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 folloking reason:
Commercial Building Y=,f
EXEMPTION NOT APPLICABLE"
This certifies that school facility fees imposed pursuant to Government Code 53080 in the a noiwt of
.33 X 5,344 or $ 1,763.52 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 cc/First Community Bank/Rod Murphy Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Olivia Aguirre Payment Received $1,763.52
Check No. 098038
Signature
NOTICE: 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 date on which the building or installation permit fo,r 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