9511-153 (CP)LICENSED CONTRACTOR DECLARATION
N I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
oC) in
^ License is In full force and effect. 614611 C53 10 i
� n idcense# Lic. Class _3i�
,Date_-,?
Z ^ %'Date /;1 1 45' SignatureofContractor
P di OWNER -BUILDER DECLARATION
LLI W 1 hereby affirm that I am exempt from the Contractor's License Law for the
D- 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
Cl) Date Signature of Owner
N
0 rn WORKER'S COMPENSATION DECLARATION
a Q I hereby affirm under penalty of perjury one of the following declarations:
C) Z () I have and will maintain a certificate of consent to self -insure for workers'
rn FQ-O compensation, as provided for by Section 3700 of the Labor Code, for the
XLU tl performance of the work for which this permit is issued.
Q J J () I have and will maintain workers' compensation insurance, as required by
M Q U Section 3700 of the Labor Code, for the performance of the work for which this
p U permit is issued. My workers' compensation insurance carrier & policy no. are:
aLOCarrier STATEr-UND. Policy No. 1270111393
? Z (This section need not.be completed if the permit valuation is for $100.00 or less).
00 5() 1 certify that in the performance of the work for which this permit is issued,
d 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 provisi ns of Section -3700 of the Labor
W. Code, I shah fgrthwith comply with SAe)p�sions�,,� f%�
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, intarest 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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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.,ourposes.
T>
LSIg sure (Owner/Agern)
A"'
BUILDING PERMIT
PERMIT��T-11�.�
DATE I If-10I.YZ
VALUATION :fit# # I
LOT TRACT .
JOB SITE ADDRESS 79105 HICi HO)r N TRAIL
APN
OWNER
CONTRACTOR
MCINTYRR POOLS �. SPAS
1 (
i4f1"JIS":RELU-P,A.INTE.D C011.1~,
4630.1 ROWEL IJANE
30445 YlOUITf rN SHADOWS RD
LA QUINitA CA 922515
LAQUINTA CA 92253
(619)342-3521 CBL# 1945
(619)564-1949
DESIGNE RIENGINEER
USE OF PERMIT,C}QL �' NDIOR SPA
FEE DESCRIPTION
FEES
POOL ANI7/OR SPA 15,000.00 L.8
ESTIMATED MST OF, CONSTRUCTION
15,000.40
PE-fo4:fd' FEE AlI1VIMARY
PLAN C11EC'K FEE 101-000-439-315 $105.30
C(7NST1 =11ON FEE 101.000-41 S -OW S 1 62.Oti�
MECHANICAL 1`Ia..E -- POOL 101-000-421.000 $24.00
ELEG'17RICAL F'hX, -- POOL 1.01-000-420-000 $45.00
PLIMBINTO FEE -- POOL 101-000-419-000 $27.00
'
-70 AL CCaMRucmoN AND PLAN C'ffCK:
$363„30
j ,SUB
! LESS PRE --PMD 1 ECS
$0.00
�fOTAi. PERMIT FUS DUENOW
DEC 05
B
$363.30
RECEIP'
DATE
BY
DA IRNALIF,
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
;r 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 Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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
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
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
Date 9/19/95 1 Type of Permit I La Quinta
No. 113692 Permit #
Owner Name Ministrelli Construction Log.
No. 79105 Street Big Horn Trail
City La Quinta Zip 92253 Study Area 125
APN # 769-550-010 Tract # 126152 Lot # 17 Square Footage 1
Type of Development I Single Family Residence No. of units 0
Comments Granfathered
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:
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Mitigation Agreement
in the amount of 628.00 x or $ 628.00 have been paid to D.S.U.S.D. for
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.
) I
y"\1'. 4
Fees Paid By Ministrelli-Painted Cove, Inc. Tele -1849
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature dg PA�12AAJMA_
Payment Received. -
$628.00 Check No. 2072
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