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9702-044 (SFD)LICENSED CONTRACTOR DECLARATION T 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 d. 5:351 13 MU 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). ( ) 1, as nwnPr 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. (A I have and will maintain workers' compensation insurance, as required by Sjdction 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. 1'tINMritiat) Is ii4'tJiiY.4K� (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 Sec@on he Labor Code, I shall ft rthwith comply wiih,thod provisions. yDate:�(' Applicant l ,fir t Warning: Failure to secure Workers' Co pensation 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 pr(5pe`rty for inspection purposes. * \ N1 t Signature (Owner/Agent) � C4c+,�� \-s ':� Date ' " BUILDING PERMIT# N /v=1 PERMIT G PER CONTROL# S►7�)-(W+� 4890 DATE VALUATION ��ilY i2�(l�l LOT 4 TRACT- 111K '111) V1.1 JOB SITE ADDRESS 59"2.5 AVENIDA RA �IlR.�n�.. APN 774-295-016 OWNER CONTRACTOR/DESIGNER/ENGINEER 1:A,VI+? .ROSS IMILT iER P.Af.' V1. *11AM� P.O. BOX ; Z'?. P.O. 1301K 722 (,A tit_}iN'i A. C'A 102253 LA QUIN'TA CA 92253 - iGi5fj5E,�-d)�73 C'I�A.,t� 1155 USE OF PERMIT iii -4) - . JkRWf t' DOE -8,140 i INCLUDE LILO . K WALLS Oft P00L.PLAN i 14iHS ttl;1AI(;:i D FOR iVlt>l:'1'll!LE,18 3(X' 0 wAMJi P1,AX lORf; IJAIA I(o 42-00 SF liARAktwl::/G.AhWACC 4$0.11(1 SF W� 'I114: ED CONT iii+ t�'C�NSTRIUC`TION 861902.40 e'_ti:alV„3'Cl21Jf °.Cft�lid f•"!7L iUl-i?iN!-dtii-t�?1j SSlil.tlt3 r�tnt4c'1tli�`t�'l�F�f7 tnl-4ifa0-:i�a.�iR st2^.x-� M '• f4tl.R;!lt�tdl�;tl.l. I lifs 3t,lgrtuti #2I-lh�C! w ° faf.1.101'kls:Al, Milli 101-000-420400 $la2.t(3 � � W IJiifi�,RtlhfCf4't=i if)7-fH3{i-•d3d�}-!Y'111n.'j�0 R1rl5f! � Q ( ryry �y IIV011014 1'+;1: • U:�i.{e:� i(}f��'I a�i•Fi.-Vvts '�it,t)`� OG W oitt< AN(1 1"VH sd l�'kA`!I}tl.iG"!'flltl: Ff,'Ji 22.540443-312 V'94,, 71 U_ (4) � Q LL U ; i_1W(" YFA . CONIS AUCIION AND KAN CHI:(:'K $1,0041 fh) LESS Ia£lEAII NJD BEAT'S ` 425f) 00 TMAgg pq may. ` 01- S2,75400 2ry0 RECEIPT DATE BY r 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 0 Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wail Insulation Condensate Lines Party Wail Firewall Exterior Lath Drywall - Int. Lath Final Final TtPOOLS BLOCKWALL P ROVALS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg- Test Final Gas Piping PLUMBING APPROVALS Gas Test ,. Electric Final Waste Lines Neater 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 IV 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) COMMENTS: 4 47 Building ? ; erf r1 Address Owner • u��� . R7o2: = d�4 P.O. BOX 1504 - APPLICATION ONLY 78-105 CALLE ESTADO CAL Z LA.QUINTA, CALIFORNIA 92253 Mailing Address City Zip Contractor c Address p State Ljc. v I City & Classif. Lq � S 8) Lic. # Arch., Engr., Designer Address Tel. City Zip State Lic. # 1 \ LICENSED CONTRACTOR'S DECLARATION I here y affirrp that I t licensed ynder provisions of Chapter 9 (comrnencin with Section 7000)tbf Division 3 bf t e Business and Professions Code, end my licence is i full force and BUILDING: TYPE CONST.. . OCC. GRP. A.P. Number ? ` I `f !-1�T _771 -2-157-01 Legal Description L6.[ 6uz- 3 in,, Vi -9 295 Project Description No. Stories No. Dw. Units ❑ Alter C Repair ❑ Demolition ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following Estimated Valuation Sq. Ft. Y Size Plan Chk. Dep. New ❑ .� � Add No. Stories No. Dw. Units ❑ Alter C Repair ❑ Demolition ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following Estimated Valuation 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 Distances: PERMIT Plan Chk. Dep. 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). 17 I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal. 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 Const. 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 Mech. Electrical 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.) Plumbing I'1 I, as owner of the property, am exclusively contracting with licensed contractors to con- struct 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 S.M.I. such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) 17 1 am exempt under Sec. B. & P.C. for this reason Grading Driveway Enc. Date Owner Infrastructure a 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 ❑ 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 it the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of ihV 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: 9, 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. I 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. Signalure of applicant Date Mailing Address City, State, Zip BUILDING DIVISION V AMOUNT V(.'.7)1 TOTAL ZjO. UU REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line .4. A Side Street Setback from Cent ine Side Setback.from ProlaAt FINAL DATE INSPECTOR FEB gJ97 Issued by: Dwe Validated by: V Validation: ' a t5 CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. -SO. FT. @ $ 2ND FL. SQ. FT. r@ POR. SQ. FT. @ GAR. SQ. FT. @ CARP. ,SO. FT. WALL -S0. 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 BONDING FLOOR DRAIN MECHANICAL FEES FORMS WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GAS (ROUGH) GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED OTHER APPIEOUIP. LAUNDRY TRAY AIR HANDLING UNIT CFM TEMP. POLE KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE, TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. @ c BATH TUB SO. FT. @ c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SU. FT. RESID @ 11/. c SEWAGE DISPOSAL SQ.FT.GAR @ 3/c HOUSE SEWER REMARKS: VENTILATION GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE [PL.CK.FEE 7ONST. 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 APPIEOUIP. 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 I� mares r vn a arunN � �ncarmr r rs�w GARDEN WALL FINAL Notice: Document Cannot Be Duplicated Desert Sands Unified School District 82-879 Highway 111 Indio, CA 92201 619.-775-3500 CERTIFICATE OF COMPLIANCE Date 3/28/97 APN # 774-295=016 No. 15376 Jurisdiction La Quinta Owner Name David Ross Miller Permit # No. 54825 Street Avenida Ramirez Log # City La Quinta zip 92.253 Study Area 110 Tract # Lot # Square Footage 141 Oil 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 it 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 Low°be,issued Fees Paid By Capital Bank of North County` TeleNhor.e ;;564 0273 Name on the check k By Dr. Carol McGrew Administrator in Charge )•' l t Fee collected /exempted by Pauline Pearson Payment Received $2,594.40 Check No. 5183 Signature D IN AA -01-l'— 40TICE: 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 pmtest 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 sssued or on which they are paid to the District(s) o. -to another public entity authorized to oollecl 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. s` Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting s