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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. DWp
133503 BI
Date/(;ignature of Contractor
'`O`WNER=BUCLDER 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&RC. 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.
( ) 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 agre2)that if I^ uld become
subject to the workers' compensation pro0isions of,Section 670�of the Labor
Code, I shall forthwith comply with tho a Fivi i ns.
Date: �� — /Applicant( ,.� r
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 compensat on, 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 for i96pection purpoSp9N,
_Signature
Date-
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
.i' $404,799.00 s 1' 29147-2
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR /DESIGNER / EN INFER
r
:��,C�,�����°[1��Iy}�.,:��
W' ; { �:�{.^t�
3,l1�4� �,CY�d' RTJC°r10W INC'
♦h� ya�,1w,
55-#161 LT4-di1 �`Y,1(:+.C.%SI"d .6"�:f. S
-lp�t�'F.li2'1�/:,E.
.S�'4...� .Pe 466
LA QTM4TA C"A. x+¢:253
LA Q't7lM CA 92253
(760)564,4.837, CM L0 ?4x37
USE OF PERMIT
kr.�iGM,1 AMMY DWEL . 40
NVID -1XJT $1, PLAN 293. PERMIT D01M 401' .ENCi,UDE KLOCK
CUSTOM CONYMIC It' N 4,824,00 OF
9}tiRt;."HIPAT.IO 996.80 SF
CfAlZAe4.@7�1{:�sfd1'C.'Tt'I'•�bi,'� F�s�9�.9'6v
F,MTHA�`;1`I) C1067 (XV C4;JtNIUMMICT1014
404,75W.W
C0148°I'%ZI.It" TION FEE 101-000,418-000 8 117 .W
PLAN 4"FBI:CK"M 101-000-439-318 81,37A,21
R54I,.`4.KANICAL FRE 101-000-421.000 S141SO
'el-MTRIC:AL YPX, 101-000-420--000 V r/.56
KAAADIHO FFF, 101.000•-419-000 52:175
:I7'RONCI Frib`9ION r189 o RLIZ-11- 101-000-241.000 €40AS
(ILI IMAN0 K, it i 01 -000-423-NO
DINLeWP M, IMPACT ME �1,34t'7.fbFa
.`tx�yyu�'ww'P'rrIN-PyyIgqTBEeLICiflJst'.V2- MINE 701 -0004:55-000�SnFin,fJ9l
o4
c p7;.t'.. .y.�&•S'W✓bFr 101...0/J41"�l39— 319 ' 600.0
('.ON131`1ZY.XM:CJ1`8 JWD 17j�.i'+�'
7DDrV
PEWMFIM115 DW NOW
5.75M
JUL 9 2001
CITY OF LA OUINTA ;
j.aQEIPT r flti V
fBY
DATE F ALED
INSP T
-
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A
01 1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings �
�'! —_
(_/( p� _
Ducts
Slab Grade
!d /
Return Air
Steel
_ _
Combustion Air
Roof Deck!�
6�
Exhaust Fans
0. K. to Wrap
_
�_ d 6
F.A.U.
Framing
�%_ a�0�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - W. Lath
Final
_
81! 3 (p Z
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
��i
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans_
Sewer Lateral
Sewer Connection
O.K. for Finish Plaster
_ _ Pool Cover
1911i7'71- r _ Encapsulation
Gas Piping
Gas Test gI4%g
Appliances `
Final
COMMENTS:
Final
"/V `IQ�
Utility Notice (Gas)
7
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
a
Final
_
Utility Notice (Perm)
i v ✓ - - .moi --v—T.#
Building 67- 725 d?444L
uC�l'II,rCv
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
AkoUy LA QUINTA, CALIFORNIA 92253
Address 55- oj�LS
City Zip Tel.
L4AjiJ A 9a 2i� 3 1 771-17491
A.4411.44 lQJS i iWsiC-1iDA1 We—
Address e -
Address ,v
75? -,a7, -.v G°wlz C�saOl Z
I'Z 213 � 7GAlOo
State Lic. City
& Classif. 7����3 Lic. # 3-2 3'7
Arch., EngrI
Designer FFE f .4, WI ZEK i A%041IA T e5, W&
Address Tel.
/ o ` - S,16 -43;
City Zip State
/'. -74 lb4ES14 44 9Z1o2ln Lic. # e21 J 72
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER•BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
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
Division 3 of the Business and Professions Code, or that -he is exempt therefrom, and the basis
for thealleged 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).
I] 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, Bu/mess and
Professions Code: The Contractor's License Law does not apply to an owner of property who
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
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.)
I 1 1, 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
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
Date Owner
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
n Copy is filed with the city. ;n Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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: 11, 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 if 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 -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
ILDING: TYPE'CONST. OCC. GRP.
'. Number 74 / - f&0 - DG y — 6'
jai Description l® --r _57 of uac T 2f1 ,117-2-
jectDescription Y/Ale,& 1�AW1r1L`f WESt,7-dGE
A040a yX78
Sq. Ft. ��,.��No. No. Dw.
Size Ft.
721 Stories / Units 1
New )& Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Coachella Valley UD" Sool District
P.O. Box 847, The. mal, CA 92274
(760) 399-5137, Ext. 235
This Box For District Ose Only
DEVELOPER FEES PAID
AMA:
AMOUNT: RM 1.
Cit r. cAsx
tNr LU& DAT&
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project, Name: I Date: July 9, 2001
Owner's Name• Wers-kopt Partners 11 LLG Phone No.
Project Address:5'7--725-Black Diamond, Quinta, CA
Project Description; Single Family Home
APN: 761-860-005 Tract #: 29147-2 Lot #'s: 51
Type of Development: Residential ' XXXM Commercial
Total Square Feet of Building Area: 4.824
Industrial
Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement
under penalty of perjury and fiirthcr represents that he/she is authorized to on belt of the owner/developer.
Dated: % " I Signature:
rrrrrr+errrrrrrrrrrrrrrrsrrrrrrrrr•rrrrr:rwrrrrrrrrrrrrrrrrrrrrrrrrrrrr
SCHOOL DISTRICT'S REQUIREMENTS FOR TIMOOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project Agreement Existing Not Subject to Fee
17620 65995 Approval Prior to 1/1/87 Requirement
Note:
Number of Sq.Ft. 4,824
Amount per Sq.Ft. S 3.34
Amount Collected S 16,112.16
Building Permit Application Completed: Yes/No
By . Foch "rut" Pensis Assistant Superintendent ed.,,inistiative Services_
Administrator in Charge
c
Certificate issued by: Elvira Mattson . Czbe-- Signature:
Section 66020 of the Government Code asserted by Assembly SM 3081. eReedve January 1.1997, requires tbat tbis DWdct provide (1) • written notice to
the project appeusnt, at the time of payment of school fsts. mitigation payment or other eucdons CFecs"1 of the 90 -day period to protest the Imposition of
these Fees and (2) the amount of the fees. Therefore, In accordance with section 66020 of the Goveramsnt code and other applicable law. this Notice shall
serve to advise you that the 90 -day protest period In regard to such Oen or the rafidity, thsrcof commmca with the payment of the tees or performance of
any other requirements as described In section 66020 of the Government code. Additionally, the amount of the fees Imposed Is u herds set Will. whether
payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the latter. the 90 days starq oo the date 6This
nod b
Certificate of Compliance Is valid for thirty (30) days from the date of Issuance. Extension will be granted only for good cause, as datermloed by the School
Dastrict, and up to three (3) such extensions may be granted At such time as this C"licate expires, If a building permit has not been Issued for the project
that Is the subject of this Certificate, the owner will be reimbursed all fen that were paid to obtain this Certificate of Compuanee. Rev. 09/27/99