9610-053 (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 Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
b/•12538+1 to \ r 13110
eA0� S' , Signature of Contractor
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.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700i of the Labor Code, for the performance of the work for. which this
+�Ast yR't j}ill ! t.'.!HIa6hYNy_Y/:,
permit is'issue : My iv, compensation insurance camer & policy no. are:
Cartier Policy No.
(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 Sect 3700'of the Labor��
Cede, I sh 11i forthwith comply withlthose prlov slops.
bate: {` /. aI+t 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 inspection purposes.
Signature (Owner/Agent) t• 1 �' '^�^^-^"' Date
BUILDING PERMIT PERMIT# CONT("1151
yb'�"51 42 24
DATE iOfIW96 VALUATION sfXi M-00 LOT TRACT
JOB SITE 93.30:+t1Vi NIDA KUH10
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PACA IC IRAC:)ES
PACIFIC"T.1:A02
P.Q. 13O 7.22
P.O. 80X 722
I,.A QUIN"3'A CA 91233
GA QUINFA r -A. 92253
(t►'�,tgcc,(•�'t7�
(FI91.V14.0217A C13I.# 1055
USE OF PERMIT
r'tilldt.I;:,f: !•ARI(f,� ),a1A'1a.l,IN�i
41E: N1JT 1'X:Ph: { i (Yl' It°iCIA 10F BLOCK WAIL OR POOL.
ir;S'1'3;R1,i"ICED €.+1ST OV C+;)bTR'iRtl{:'i iON
iiG.l�2.Qi1
��t"afq�?'(7ti te� !'(t7N i•7iis` f u l •Otit)-�i f it•4�H) 3;ft t rill
!.,,LM `t'1 4; FERE 1 I 139 -31S $191 37
Fir-11,1);�k'tJSIT a25),W
t_p
( W(.1IANW'A[. A -1W (fN -t1t wl, l _W0 353.5t)
( 1JX f'RfCAI, FT -.r 101 4911.420-000 -000 5122.$31.
r't.Lt:lt3t'.O!?:li tttl- ?'1st1, $127.50
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INVKAN"f'O1b-I'tff?1, 11-11; .-
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PLANtsti.{}i}r�• ! i1 3 i; !n ftp+
D
SUB -'3t MAI. CONTS'IT;WITON AND PLAN CHECK
�3�3T..ci4
I,LSS 1IRL-PAID IVES
-$2.%.O0
'f'C)'i'AJ, 3'I ANI I'll' FE RS DIIC NOW
X3,122.62
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 & Controls
Party Wall Insulatior
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL AP ROVA S
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 12 /31
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole jJ
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of PoweG
Final /
Utility Notice (Perm)
- a
P.O. BOX 1504 APPLICATION ONLY
c, 7&105 CALLE ESTADO
Address �� T� t LA QUINTA, CALIFORNIA 92253 /—\ n
Mailing
Address
City j
�.onuactor l /
DI
BUILDING: TYPE CONST. FOCC. GRP- i
qoS� V�/O —1 2 �U I 1 IZIJ0 LL
A.P. Number / 7 L �'� 1 - 1 1 /
`% �7� D
Zip 2
Tel. '
2� Legal Description �J
City Zip Tel.
State Lic.y
& Classif. •5q7,53(91 Sc.Li#
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that lam licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
[] 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
[I I, as owner of the property, am exclusively contracting with licensed contractors to con-
s
truct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 I am exempt under Sec. B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
r3 Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
1 agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant -Date-
Mailing
ateMailing Address
City, State, Zip
BUILDING DIVISION
Description
Sq. Ft. f/
Size _1
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR .
Issued by: Date Permit
Validated by:
Validation: _
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
+Oa
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
`
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR .
Issued by: Date Permit
Validated by:
Validation: _
CONSTRUCTION ESTIMATE
NO, ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. (a $
2ND FL. SO. FT, d
POR. SQ. FT. C%
GAR. SO. FT. �.
CAR P. I SD. FT.
WALL SO. FT. ®
SO. FT. @
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
�^
NOTE: Not to be used as property tax valuation
HEATING (ROUGH)
FLOOR DRAIN
FORMS
MECHANICAL FEES
ROUGH WIRING
WATER SOFTENER
ROCK STORAGE
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
HEATING (FINAL)
APPLIANCE DRYER
REINF. STEEL
GARBAGE DISPOSAL
TEMP. POLE
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
WATER HEATER
AIR HANDLING UNIT CFM
FINAL INSP.
KITCHEN SINK
BOND BEAM
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
=$
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
FRAMING
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. (a c
BATH TUB
VENTILATION
SQ. FT. r< c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ, FT. RESID ® 11/. c
SEWAGE DISPOSAL
FIREPLACE
SO.FT.GAR n 3/,c
HOUSE SEWER
SPARK ARRESTOR
GAS PIPING
GAR. FIREWALL
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 & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH 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 APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
CU. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
--
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESANITIALS
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 10/18/96
No. 14935
Owner NameDavid Miller
No.53405 Street Avenid
City La Quinta
APN # 774-.072-018
Jurisdiction La Quinta
Permit #
zip 92253
Log #
Study Area 111
Tract # Lot # Square Footage 1410
Type of Development Single Family Residence No. of Units 1
Comments
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 1.84 x 1,410 or $ 2,594.40
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 Capital Bank of North County/David Ross Miller
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson
'Telephone
._
e.
Payment Received
Check No 4327
$2,594.40
Signature IJJ'AAo J
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
COACHELLA VALLEY WATER DISTRICT
-+�
v
CASH RECEIPT DETAIL
Received From: L
l / -
t-,
Date: 10 l
Address:
^G
Account No.
Lot(s)
Tract
��i _
Service Address — '
G.A. Code
Meter(s)
6 ®•
Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
\1 Sanitation Capacity Charge¢a
'❑\
�'
/ f� S• ' !��
W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
�%
TOTAL
$
Remarks: -t
❑Copy to:
/
Water Service
Cash
Check
Money
Cashier
Order
r
CVWD-438 (11189)