0206-082 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am liceh'sed'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
533670 's fuc 6/'301c1i
Date j� �`� `' ? Signature of Contractors3.--
'� OWNER-BUILDERED CLARATION
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.
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 5VT)~r FikEj'1� Policy No. 012
(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 ttje workers' compensation provisions of Section 3700 of the Labor
Code, .l shall forthwith_ comply with those'provisions. v
Date: ! �': �� 2, Applicant
Warning: *Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer,,to;criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees;
2. Any permit issued as a result of this application becomes null and void if,
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for nspection purposes.
Si nature (Owner/A ent) ---i- -,; ' "-2-- --A -`"a Date ,
BUILDING PERMIT PERMIT#
02=ice
DATE VALUATION !a. LOT 1 TRACT�•���
�,.
JOB SITE
ADDRESS 717-90UR90Ce CIOU -,
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
�G�k,T .1idA�
SfT1.T.C. M. i OPIPO;C'tKIIJOINT
77.56 COMMYL'L'UB D WVE 0137
77.645A 4 OUI,17RY I ..IlD'i)"R,iWE 3'( TM, 150
PALM Dr-ZMT CA. 92211
PALM W:.S'W cp. 92264
C`/64')772 -V224 M:i# 1137
USE OF PERMIT
* .
Tp�',, TylyU�9t�r,Kfl2Pyftpl4•rtCo►F28:a Ct71.tA�A
y.tipJ�py°i, p 5��.:r'.ri"BeJQpPM R'It�$p1dC+?d7' nC��AR
1X93'V,1%p�•�7cLr TO 6�,:C.9�[i.M.aA �� MUM d�db'a'W RI I iAG f«ONSI166Vhir� F�N. , PER. i
CUSTOM 3F
'11 '1' 1'. (.'.`•0�'1' OF C01101-TWER711DY1
-�.�g`�$ p y ^�, y.s ,�}q�d,� gt
V RS.dl�:�1�ii .17 ER 49i.'A'Y� b:Y.7A
rZECTRICAL FE.Y.. 101,000-420-000 .bts
ART IN PUBLIC kACBS.. RESIE 270-000-445•.000 Vo i
PIMA lV'kEiKI FE 101,-000��� 39.3181 397.71
wrwoom
L
UIifawp
EPT
SUB TO fAL CONMRUMON AND PI" CWZY.
LOS IME -PAW
$000
IWAL PERMt I 51 DUE NOW
i
$121,07
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
sinal
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 I I
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 Votta�ge Wiring
Fixtures `
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
p�
C� O 01
.3
-
,
Notice:
Document Cannot Be Duplicated
Date 6/14/02
No. 23294
Desert Sands Unified School District -
�l�IED
47-950 Dune Palms Road
La Quinta, CA 92253
'Q BERMUDA DUNES
760-771-8515
C/) RANCHO MIRAGE t7
INDIAN WELLS
PALM DESERT
CERTIFICATE OF COMPLIANCE
`�
T LA QUINTA L
INDIO
APN# 773-022-021
Jurisdiction La Ouinta
Owner NameSedona Homes
No. 77915 Street Laredo Court
city La Quinta -Zip 92253
Permit #
Log #
Study Area
Tract # Lot # Square Footage 200
Type of Development New Residential Addition
Comments
of hobby room to new construction
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:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.14 X 200 or $ 428.00 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 CC 1st Bank - Lance Alacano Telephone
Name on the check
By Dr. Doris Wilson .
Superintendent r
Fee collected /exempted by Crystal Scott Payment Received $428.00
Check No. 62890
Signature
IOTICE: Pursuant to 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
bove 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 DistrictCs)(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
i
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