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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 ncing 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 this reason
Date �,a n A 0 J Signature of Owner
WORKER'S COMPENSATION DECLARA ION
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).
( ) 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.
Date: 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 underOr pursuant fo
any permit issued as a result of this applicaton agrees to, & shall, indemnrfy
& 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 forinspection purposes.
,Signature (Owner/Agent)r ' -dDate
,� t.•✓ x'
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
dif�t� 7fir
JOB SITE
APN
ADDRESS
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w�'+e.4555 Aro E. Sa t�!ib+.4a.+
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MOK. �f���F i?�i
t 3� I. L•fib .
54.655 AW, BERMUDA
LA gvwp CA 922S3
USE OF PERMIT
Ift L. F. OF 6' 81,OCK IVAI L •• CITY ST.etsND.P.RD
6'". TATALL 10A LF
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0 9 2000XY
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RECEIPT
DATE _ 3pp
-.
BY`
DATE FINALED
INSPECTOR
,BY*
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE 7T
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
et Backs
Underground Ducts
orms & Footings
Ducts f
lab Grade
Return Air ~;
„teel
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 Insulation
Condensate Lines
Patty Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings _ _
Bond Beam ��'�6 '� S7
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
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)
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 10/12/99 APN # 774-285-008
No. 19434 Jurisdiction La Quinta
Owner NameMark & Janine Johnson Permit #
No. 54-655 Street Avenida Bermudas Log #
city La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 127
Type of Development Residential Addition No. of Units 1
Comments
127 sq. ft. residential to single family residence.
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 127 or $ 0.00 the property listed above and that building '!
permits and/or Certificates of Occupancy for this square footage in this proposed project may pow be issued
� w i
Fees Paid By N/A Telephone 771-3444
Name on the check
4
By Dr. Doris Wilson
Superintendent ,
Fee collected /exempted by Juanita Green Exempt $0.00
Check No. N/A
Signature
NOTICE: Pursuard of Asgembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9"ay 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 Distrid('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 DeptJApplicant Copy - Applicant/Receipt Copy - Accounting
PLAN CHECK CORRECTIONS
DATE: Z2-110 ��� PERMIT #
JOB ADDRESS. Sy h W
CONTRACTOR,
PLAN CHECKED BY:
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