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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. Date
59.5754 D1 (.19 � 06 WIr
�D `4 -'24 -1, Nignature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exgmpt 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.i5 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). ' 1
( ) I am exempt under'Sectiori , B&P.C. 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.
3°fATE FAD 229-m t&2uT 00110m
(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. rovisions of SectiT 3700 of the Labor
Code, I shall forthwith comply with tho&e p ovisions. .
Date: �`-� T Applicant
..�
Warning: Failure to secure Workers' CorApensation coverage is unlawful grid
shall subject an employer to criminal pen�lties 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. a'
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 forinspection purposes.
,Signature (Owner/Agent)
Date 1a
P.i3�,t.J�De7n'
BUILDING PERMIT
PERMIT#
DATE VALUATION LOT
()J.Q!� .223 TRACT
,
CONSTRUCTION F
JOB SITE
Wolxi
APN
ADDRESS
1; �0TEc�13�RUS"R..
'101-1%1*0.4139.318
64&31.2-018
OWNER
CONTRACTOR/[ / EN (NEER
PNZ WkMI :t CHOIT co
P.AT C0NVo'T1dUMON CO
hRWi%APdACAI.. ER, '
iAQtvm _ CA 92233
LA QUINTA CA 12253
(760)564.3023 CB19 55,31?
USE OF PERMIT
3110; 6
WID .• PYRAUT-DO NOT MC'.f.40Z i3Y1)CK Wi AULP.-PAAlPOOL OR
101-.000-419- 00
$f.ani.00
W110140 MOTION F99 - RIS115
!11141, 90*41.0,00
�`Tt.,F�wi C'ONu'4'I,�•t��'.4taA�
1,'7��.0i3 Vit:+
�paR�v��.Ip:�(5r��a{��{;,��':;iggp�`@$i]pp��•�n
101 -000-423-000
�y2M�.t��yn
'4YBRR,6`6'VtS7kr.7YRS's�d�E tST�
5?y�77�+�QN
g7
st'i"V I'm
P.i3�,t.J�De7n'
yq F,�y'�p y;7��,'��p �1 A,pEfVT
.1�•�bY.�T+.1.:6�� .�! 1N3�% 8UNW. RY
,
CONSTRUCTION F
101-000-046000
Wolxi
€ LAN CH7FIICK IR'ft
'101-1%1*0.4139.318
$546.91
"Mr.CsEPOW1
1101-000-4.39-318
-3290.00
hRWi%APdACAI.. ER, '
t 01;-OCKiw2.9 -OUO
451315.0
91,R f'UCALMY
3110; 6
PLUMB 00 Ptp.
101-.000-419- 00
$f.ani.00
W110140 MOTION F99 - RIS115
!11141, 90*41.0,00
$10.5
�paR�v��.Ip:�(5r��a{��{;,��':;iggp�`@$i]pp��•�n
101 -000-423-000
�y2M�.t��yn
fi
M1UY.4yA� P.ER IMP.PIC, RT F18K
g7
st'i"V I'm
-- !()B G�°�t�T COI�i�31"P 113(1T f.0R �A,Mt) C'i,.h,W C' WCX T-3,44 1.90
n n qy T,�.�3y��yp�Sp'y�1yr�.y-PAI D:� UN) x}4250.00
.L�iL.{Tt!Y 1A $',�ui�nA71 .Ar V 911 1@�c.o�y'R 4E�uyt1srye.+ 0 I
MAY 2 9 2001
RECEIPTFINANCED BY DAT FINAL INSPECTOR
„l e•,
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade
r1.O�
Return Air
Steel
Combustion Air
Roof Deck
a-'1- o
Exhaust Fans
O.K. to Wrap(_
Framing
m t
dt
�%
S-7
- 5-7
F.A.U.
Compressor
Insulation
'7- -p
S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Finall _`11a�-
BLOCKWALL APPROVALS
Final
POOLS -SPAS
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
Water Piping
Plumbing Top Out
_/ _
[/ f l0't
J
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection-
O(
Pool Cover
Encapsulation
Gas Piping
Gas Test/lTZ
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lowy Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) �/
4 4 Q"
2 P.O. BOX 1504 APPLICATION ONLY
Building fy- 78-495 CALLE TAMPICO
Address C .- J�Giw,'l! Lrg,r,r}LA �UINTA, CALIFORNIA 92253
Owner
V
Address ,
City Zip Tel.
Contractor
Zip
Z�) ED t_
State Lic. City
& Classif. �� s� �4 Lic. # _,(:5 3
Designer C� � S
Address Tel.
,d _ Q -4,d. U rt_ t _t of I 1 #A, J -,k2
City (Zip (State I
��
I _ - N r t/Yr . LIC. #
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 Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, altar. 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 the alleged exemption. Any violation or Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
1] 1, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If. however, the building
or improvement is sold within one year or completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I.1 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor($) licensed pursuant to the Contractor's License Law.)
17 I 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
r7 Copy is filed with the city. O 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
Of 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.
Date Owner
NOTICE TO APPLICANT: If, 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
Ihereby 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 fof inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 6 0 tt
Legal Description L0_T %V, b ar lL aoz
Project Description �� I -, ► 1:r-- *,A. *� 4,-rr
Sq. Ft
Size
New
No. No. Dw.
Stories 4 Units
Add O Alter ❑
on
Repair ❑ Demolition ❑
PERMIT
AMOUNT
Plan Chk. Dep.,-�
3
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 S nter Line
Side Setback rl roperty Lie
FINAL DATE U ECTO (
Issued by:D[31�� 1�...Pe� i;
Validated by: 1�+�111� L I
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
FINA" wulfy
N_NCE DEPr
Notice:
Document Cannot Be Duplicated
De'sert'Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 5/29/01 APN # 646-312-018
No. 22053 Jurisdiction La Quinta
Owner NamePaz Construction Permit # 0105-223
No. 78-685 . Street B.ottlebrush
City La Quinta Zip 92253
Log #
Study Area
Tract # Lot #- 68 Square Footage 1,768
Type of Development Single Family Residence No. of Units 1
Comments
*Received payment with a Cashier's Check for $3,554.70, and also received $69.70 cash
money. Totalling $3,624.40. `
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 tot, Government Code 53080
2.05 X 1,768 or $ 3,624.40 the property listed above and that building
permits and/4r Certificates of Occupancy, for this square footage in this proposed project may now be issued
Fees Paid By CC/ Canyon National Bank- Agustin Paz Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Paula Ruiz
. s.
Signature
in the amount of
Payment Received
Check No. 07110
$3,624.40
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. i
t
Collector: Attach; copy of county or city plan check application form to district copy for all waivers.
Embossed Original; Building Dept./Applicant , Copy - Applic'Lt/Receipt Copy - Accounting
Certificate of Occupancy
City of La Quinta
Building and Safety Department
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: 787685 BOTTLEBRUSH
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0105-223
Occupancy Group: R-3, U-1 Type of Construction: VN Land Use Zone: RM
Owner of Building: MR & MRS AUGUSTINE PAZ
Building Official
Address:
52-995 AVENIDA MENDOZ
City:
LA QUINTA CA 92253
By:
KIRK KIRKLAND
Date:
JANURARY 7, 2002
POST IN A CONSPICUOUS PLACE