0110-105 (SFD)• LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H CJiapter 9 (comme6cing with Section 7000) of Division 3 of the Business and
cV W� "'Professionals Code, and my License is in full force and effect.
O 11;r License # Lic. Class Exp. Date
LLO
400.1 B C36 CW04119;?M(
6 Z r Date Signature of Contractor-
0
ontractor 0 t
~
J CID OWNER -BUILDER DECLARATION
HWa r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 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
N Date Signature of Owner
O0
ZWORKER'S COMPENSATION DECLARATION
IL C CL I hereby affirm under penalty of perjury one of the following declarations:
LID O () 1 have and will maintain a certificate of consent to self -insure for workers'
X 111 IL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
� Z Carrier Policy No.
ob �
r- a
Q (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
( Date: ' - f f- r ., + Applicant lr,
"Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application'.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby .authorize representatives of this City to enter,upon
the above-mentioned property Icor inspection purposes.
Signature (Owner/Agent)y .t % Dater
} BUILDING PERMIT PERMIT#
&TV7
DATE VALUATION L
i4.dOdT41,°2 V7,20&70 70 8
TRACT
:692 'ts21
JOB SITE.�`,1C
ADDRESS 152
APN
OWNER
CONTRACTOR /DESIGNER / EINEER
SAM09 C RWai.
VMM C. }3FJ..Na' AP, .fh.
P,t',:CO 297
73-300M, DIMi YC]- ANE
r X;11A l�1f :..'!r, CA 922611
k'.A;: T LE�°`'.�R�
A. 922161
si76131€3di�13�`�f� •
Cbv$ 21A15
USE OF PERMIT
1a 1.01'8, MAS'EM MSOWADA, Pl?:FT:1'fiIT 001&rs NOT INC.L.UDM
}�[eCiC;:►'f' �'91.1�Xrfil� 1��:�t3s�13}�.A�,, i'h'fi ��Itirf;�.A.Y'.�k�i"11.c�.P.C'€1, '�;5�h �i�„ft�Ai D
IFOR
[r=L\ u
a,';1•a.ECIX , YE;E;, TIFOUC:.vA 1(;YN 1f,1MJf .1hC S Cain 4F, PL A.14 TYPE
1
dL
OCT 10 2001
20LOI
TRAC T CC,�NSTRUC 4ION 1,604,00 S?
POR.0 k14)A'T IQ 10 4.60 Sr
CITY OF LA QUff4TA
C.IAi#AOVt`.,x+►,%,PORT 446.00 SY
FINANC,E t7aFT.
I,,`sM( A`I; D C:t" Tf U17 COMIZITC770K
7 €!lF3w 163
P1411pivaT VICE WWWRY
e"ONST11;1101DWFEE 101^000.4.18-000 $630130
VLAN CF1Tf, C1C.' liILTE 101-000-439-:31 Et s'T'�zo
krKE. DRMSIT 101.000.439-318 4250100
MEC"HANIC:&L FES 101.000.421.000 $ Pat 00
l?LT?4".'TRICALI?.Ei 103.-C# D-420.000 911311%
K:tY M1100FF14? s01 -N. 0-419-000 $1,30.00
0 k'!lC' NG MOTION VSK - REW(D 101-000-.2,41-000 09.72
101-000-4-21-000 370.N
D(+,'VF1,01 r!R W1 ACT VK9 S1,07,00
1zR,�CISIs 1b1..AN 101 -000 -X441 -3e§5 �i00.ttU
s
�f�i".Z,F�i-".0 )T:AL COW -T!, �W3 P.T.,l•��° �,":l1ECJr1
$3,116.27
LcS l+19 PRE-p'A;1� H-170 •250, C.t1,t
RECEIPT
DATE
BY
INSPECTOR
wp
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
_ _ _ _
�?j
Combustion Air
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 /7, 7,
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 _
��5. O( 5�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection((��
_
- O / ST
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Finale
U Z . LCC
Util'dy 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)
��
1'
5 s CITY OF L-A QUINTA
cFboFo BUILDING & SAFETY DEPARTMENT
777-7012
t,+ ..kNSPECTION REQUEST LINE
777-7153
I JAMES'BEL.KNAP
Owner
Contractor JAMES BE.L.KNAP
Permit Number 0110-.105
i POST ON JOB IN CONSPICUOUS PLACI
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS 52-165 AVENEDA BERMUDAS
SFD --LOT 8, MASTER- ENSENADA, PERMH-DOES
NOT INCLUDE BLOCK WALLS, POOLISPA,..OR
DRIVEWAY APPROACH
I TYPE OF INSPECTION DATE INSP.
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING C �S
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
i DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
f '
ROUGH GAS & GAS TE
HEATING & VENT- A/C
FIREPLACE
ROOF
BOND BEAM
O.K. TO WRAP
GROUT O 4' 0 8'
FRAMING
INSULATION
PRE -ROOF
i
COVER NO WORK UNTIL ABOVE AS BEEN SIGNED
DRYWALL INTERIOR J 7
EXTERIOR LATH 1 -
POOL PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC YANK�-
ELECTRICAL
PLUMBING
FINALS
TEMP POWER +
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING
Notice:
Document Cannot Be Duplicated
Date 10/10/01
No. 22569
Owner NameJames C. Belknap
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
No. 52-165 Street Avenida Bermudas
City La Quinta
APN #
Jurisdiction La Quinta
773-235-019
Permit #
Log #
Zip 92253 Study Area
Tract # B92 U11 Lot # 8 Square Footage 1604
Type of Development Single Family Residence No. of Units 1
Comments
a cashier's check for 3 single family dwellings.
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
2.05 X 1,604 or $ 3,288.20 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 / La Jolla Bank - James C. Belknap, Jr. Telephone 760-837-1566
Name on the check f
:c
By Dr. Doris Wilson
Superintendent
Fee collected /egem ted by Annette Barlow
Signature
Payment Received $9,864.60
Check No. 302530
NOTICE: 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 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 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 �.
Certificate of Occupancy
City of La Quinta
Building and Safety'Department
FA
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
52-165 AVENIDA BERMUDAS
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R3 Type of Construction
Owner of Building: JAMES C. BELKNAP
Building Official
Bldg. Permit No.: 0110-105
VN Land Use Zone: RC
Address:
P.O. BOX 297 .
City:
PALM DESERT, CA 92261
By:
RICHARD KIRKLAND
Date:
FEBRUARY 21, 2002
POST IN A CONSPICUOUS PLACE