0401-208 (SFD)LICENSED CONTRACTOR DECLARATION
"Phereby 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
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 thisfreason
bate -I' • a � Y Signature of Owner Z, J/,
0.
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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(x) 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.
Dater a 4/ APPlicant�. 1 r .�'.(�
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.
N S.C.f / •
Signature (Owner/Agent) � j/� Dated S �
BUILDING PERMIT PERMIT#
0401 -268
DATE / VALUATION .$11rj,7,jt►.70 LOT 15 TRACT PLY 5.4JOB
SITE,
ADDRESS 5,1--v96 .a1��XN]DA lii .RA]R.' Z
APN ` 1T3 -4:31.-a -10
OWNER.
CONTRACTOR/DESIGNER/EN (NEER
ttt7ALC��I �. R,I°Ii_+z:�
i�'�2e .(�t►'�U�LiCtEFt
P.0, BOX. 604
I.A QUW.M CAS 92.253
USE OF PERMIT
WNICTLE rA1.af17-.Y DWE.LJJN'(3
IWO S.'F, 3P'r9 PERMIT DO&S NOT INCLUDE fJ!t.00K WALL, PCOUSPA
OR.DFRIVii'JAY APPROACH, - - ,•
TRACT CONSTRUCTION 060.00 9F
PORCHrPAT10 443.00 SP
(JAPLACWCARPORT 4733,00 3
ESI 110) C;0811' OF C'0t`6SMU(,,7170P4
110,730,70
PTST1rlAA:Y"1C%t EE K7I4Ati"�"i,fi.RY
CONSTRUCT FRE 101 -OW -418-000 078140
PLAN Cf[ZC. C FEE, 101-000-439-318 $558.91
PEE DEPOSIT 101.000.439.318 -$250.00
MZCHANICR.L 4rl':E 101-•000-421-000 $+59.00
EL,EC'-TWCAL FEF 101.000.420•-000 $119.50
4;
PlIUJ91Z INO FEE 101-000-4,19-000 0119.00
STRONG MOTION FEE - RESIN 101.000.241.000 SI1,07
ORADINO FRE 101-(.1f10-423-000
•'i
DUVELOPER IMPACT FEE $2,40:1.00
PRECISE PIAN IOi-Q00- 1-s45 to0.11fl
. C OC7'Ct'1014AN.P. PLAN CnLICK
$i,,Qfo4 54 .,
C3401 PR&PALU TW. S
4230.00
0 3 Z004Tcy 1Pbamia- — enn iDuE vow
x'81454
CIT`r OF l A QUIN eA
FIN ANCE DEPT.
RECEIPT
DATE
=8Y.� -71
DATE FINALED6)
PE R
INSPECTION RECORD
a. 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
- cJ
Final _ D
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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 —US
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 7_
Utility Notice (Perm)
COMMENTS:
Comments
At. the present time, thebesert'sands Unified School District does ,no.t collect fees on garages/carports; covered patiostwalkways, residential additions under
500 square feet, detached accessory structures (spaces that do not'contaln.faciiities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the.above=named owner is exempt'from:paying schooffees at this time due to the following reason:
EXEMPTION. NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code.65995'Et,Seq.
in the amount of . .14X 1,760S. F: or $3,766 40' have been.paid for.the' property listed above and that
building permits and/or Certificates of Occupancy for this.square footage in this proposetl project may now be issued.
Fees Paid By CC/Citizens`:Business, Bank, Wally. S. Miles Check No� 527237
Name on"the check Telephone 760/771-4824
Funding Residential
i.
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by ^Sharon MCGllvrey Payment Recd $0.00
$3,766.40 Over/Under
Signature ilG
NOTICE: Pursuant to Government Code Secti6n;.66020(d)(1.), this w'ilkserv& J,o notify you thaHhe,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 for this project is issued, or from the date on which
those amounts are paid to the District(s) orto snottier public entity authorized to collecYthem;on'the District('s) behalf, whichever is earlier.
NOTICE, This -Document NOT VALID if Duplicated
Embossed Original - Building Departi enUApplicant Copy Applicant/Receipt Copy.- Accounting
CERTIFICATE .-W-COMPLIANCE
��1FJ>✓vs�,
Desert. Sands Unified SchoolDist"rict
opo
47950. Dune.,Palms kdid
o '
•'+ s-.-• q- -
BERMUDA DUNES
Date
2/2%04
La>QUlnta,_CA 9.2253
RANCHO MIRAGE C7
No.
25440 ' '
(760)`7-1178515
ti
INDIAN WELLSDESERT
d,� PALM
LA QUINTA y�
'
OINDIO
C9
Owner
Wally S. Mlles
AP.N # :.
773-131-010
Address
P O Box 604
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit # .„
0401-208
Tract #
BLK 54
Study Area-
Type
Single Family Residence
No. of"Un.its
1
Lot #No. Street
111111111111111
;, SF: Lot # No.
Street S.F.
Unit 1 155169.6
016
Avenida Ramirez 1760W1 Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
"Unif 9
Unit 5
Unit -10
Comments
At. the present time, thebesert'sands Unified School District does ,no.t collect fees on garages/carports; covered patiostwalkways, residential additions under
500 square feet, detached accessory structures (spaces that do not'contaln.faciiities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the.above=named owner is exempt'from:paying schooffees at this time due to the following reason:
EXEMPTION. NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code.65995'Et,Seq.
in the amount of . .14X 1,760S. F: or $3,766 40' have been.paid for.the' property listed above and that
building permits and/or Certificates of Occupancy for this.square footage in this proposetl project may now be issued.
Fees Paid By CC/Citizens`:Business, Bank, Wally. S. Miles Check No� 527237
Name on"the check Telephone 760/771-4824
Funding Residential
i.
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by ^Sharon MCGllvrey Payment Recd $0.00
$3,766.40 Over/Under
Signature ilG
NOTICE: Pursuant to Government Code Secti6n;.66020(d)(1.), this w'ilkserv& J,o notify you thaHhe,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 for this project is issued, or from the date on which
those amounts are paid to the District(s) orto snottier public entity authorized to collecYthem;on'the District('s) behalf, whichever is earlier.
NOTICE, This -Document NOT VALID if Duplicated
Embossed Original - Building Departi enUApplicant Copy Applicant/Receipt Copy.- Accounting