0106-021 (SFD)LICENSED CONTRACTOR DECLARATION
I 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
701
01
Date ~`? ±�` Aignature 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).
( )J Iam exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury 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
e tion 3700 of the Labor Code, for the performance of the work for which this
ermit is issued. My workers' compensation insurance carrier & policy no. are:.
er Policy No. 22.%.0240,2071.4
(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 shal1.l forthwith�comply with those propions. 114—
Warning:
14r
Warning: Failure to secure Workers' Comped—ssation 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 cond'it'ions 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 propertyInspection purposes, ^�
Signature (Owner/Agent�A �f t si'tr*`' `i •: Date1V 61
BUILDING PERMIT PERMITojo&oil
DATE / / VALUATION LOT 28 TRACT 21,96,11
JOB SITE��t�y
ADDRESS 1 -.�.�r� a �1SA.a r�.0* `
APN
770-;Wj-(YZ1
OWNER
CONTRACTOR/DESIGNER/ENGINEER
FA BOX 1144,
PO BOX 1144
LAAWFA CA 92253
LAQU?NTA CA :92253
(760r72-26126 (TIN 53M
USE OF PERMIT
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S'X,NIT LAWS, INMLD9 WG -TW, YNOAMMO SPECES ACT OF Thi (16
C°T)MXXM CON91.X'bi1CMUN 3,471.00 9P
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WRO3f/krATIO 54-4.00 SP
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PLAN CHECK FOR 101-000-43P.31% s i,Aqt so
FM nm>i3 lrr 101-000-4,y--418 41,M0,00
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'0 MMaMAX - 3 ug.s 101 C�10-201,1W.46 O
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AW.f IN PURI , KAC S' - PXM.V 701LL000-2'•�55.009
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CITYOF4AQUINTi�
�TNANCEDEF7
RECEIPT
DATE i ;
;81r
DATE FINALED
I11PECTQR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_>
nderground Ou
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
- X02
Drywall - Int. Lath
Final
_
Final L 7��
BLOCKWALL. APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
-
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
z
Heater Final
Water Piping
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test/�---
Appliances
Final
Final
Utility Notice (Gas) ��
ELECTRICAL APPROVALS
Temp. Power Pole •,?p-pZ
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power 3 o-2
Final
Utility Notice (Perm)
COMMENTS: G
�.Qw./O �a � -2 5 U �l .2-- U 2 �(✓�
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 5/22/02
No. 23236
Owner NameNispero Properties
No. 78-273
City La Quinta
Tract # 28611
Type of Development
Comments
CERTIFICATE OF COMPLIANCE
Street Birkdale Court
Lot # 28
Single Family Residence
'YlEt
Q BERMUDA DUNES
fn RANCHO MIRAGE b
Y INDIAN WELLS
a� PALM DESERT ,y
t.A QUINTA ,
�O INDIO V
APN # 770-280-027
Jurisdiction La Quinta
Permit # 0106-021
Log #
zip 92253 Study Area
Square Footage 3471
No. of Units 1
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
2.14 X 3,471 or $ 7,427.94 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 1 st Bank - Rob Capetz
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Crystal Scott
Signature
Telephone 760/772-2626
Payment Received -$7,427.94
Check No. 6281.7
VOTICE: Pursuant to 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
;ollect 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
F
r,
roe:
p
G OFT9� 9► Y p Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
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V
Code, certifying that, at the time of issuance, this structure was in compliance with the
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provisions of the Building Code and the various ordinances of the City regulating building
r
construction and/or use.
k
BUILDING ADDRESS: 78-273 BIRKDALE COURT
Y
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0106-021
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Y
:E
Owner of Building: NISPERO PROPERTIES Address: P.O. BOX 1144
City, ST, ZIP: LA QUINTA, CA 92253
a
�. By: KIRK KIRKLAND
k -
Date: MAY 23, 2003
Building Official
POST IN A CONSPICUOUS PLACE ORION