Loading...
9806-143 (RER)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 Professions,'.,s Code, and my License is in full force and effect. Zicense # Lic. Class Exp. Date ,,Date Signature of ContractorlN OWNER -BUILDER DECLARATION t 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 ISignature 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. ( ) 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 ry FUND Policy No. g/. .x.11. R�rl:l,�i /�'Ir11, D 4�:J'.�.o'�t!!"dGl (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 shall forthwith comply with those provisions. spate: ✓ .Applicant Warning: F� secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnity & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance !of such permit, or cessation of work for 180 days will subject permit to candellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Si nature (Owner/A ent�\��f`% t Date i BUILDINGPERMIT PERMIT# CONTROL# ` DATEVALUATION LOT 9Wiw143 TRACT 7964 _ S2,?73.0 JOB SITE APN ADDRESS 77-941 4,fi.GO DRIVE' G� A�•��Q�-�Sih�) OWNER CONTRACTOR / DESIGNER / ENGINEER TEARY DICKEY WILLIAM Fl, MUT 34W U+lE84't 9TH 66261 kOSE 1W MISSION H1C.1<.S 911+ 66491 8 N.:()9I'.ROS1 (0 81401 (470)219-975n OIL# 1.11,3 USE OF PERMIT A .)UN ;WU ANO ANO d.2i!i[490M MAS -irk .4 AITTRC GNI . ,7778.00 LS ENI h iNA ► ayin PLAN C14EC, ;,VEt: 1!)1-©MJM4�9 Sits X35.�i1 4014W -X41$-000 $54,0() 1;1XC'i'1G a^+1..4<E.1's• 1€s1.-000.4-20.009 i4Fi.5:l Y° �.Ltffvlll>fivO R-311 $TR;0NG MCYVT .7N :.FIT`, • RJ S40 10.1-000-2 41-000 S,54) ,.` 11371-Mt' L C iNS"'1'1R.L)C"f'lf. N AND FLAN clIFE'C K LESS TRX-PAWFUS $ 0,00 RECEIPT �q� A� DATE ,BYE FINALED INSPECTOR - It 1W INSPECTION RECORD OPERATIONDATE INSPECTOR OPERATION DATE INSPECTOR t BUILDING APPROVALS MECHANICAL APPROVALS Set`dacks Underground Ducts Forms & Footings Ducts Slab Grade 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 POOLS - SPAS ' BLOCKWALL 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 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 COMMENTS: , 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 C Final Utility Notice (Perm) Notice: Document Cannot Be Duplicated Date 6/17/98 No. 17196 Owner NameJerry Dickey Desert Sands Unified School District 47-950 Dune Palms Road La Quinta, CA 92253 760-771-8515 CERTIFICATE OF COMPLIANCE No, 77-941 Street Lago Drive APN # 631-400-049 Jurisdiction La Quinta Permit # Log # City La Quinta Zip 92253 Study Area Tract # Lot # Square Footage 43 Type of Development Residential Addition No. of Units 1 Comments 43 sq. ft., expand and remodel ot master RfEoom. 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 i�n•the amount of 0.00 X 43 or $ 0.00 the property listed above -and -that building'%" permits and/or Certificates of Occupancy for this square footage in this proposed pojectmay be iissued%"f 140 Fees Paid By William H. Fritz =� y Telephone ' Name on the check - :` � T ♦4 By Dr. Doris Wilson Superintendent Fee collected/exempted by Juanita Green Signature Exempt Check No. N/A $0.00 NOTICE: Pursuant of As#nbly 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 frorn 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 a a 1 L ry ry 0 CC Pot r I c a