0401-220 (RPL)U)
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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
7�2324 /3 %ITC /"� 0 >° l 112C
Date�� Signature of Contractor
- d
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 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 (STATE rMID Policy No. 15,76552-02
(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 p ovisions of Section 3700 of..the.Labor
Code, I s4114orthwith comply with th'se provisions - -
o%Date: �yt-� 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 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
th"e above-mentioned property f'r in "0 ction purpose A /
Signature (Owner/Agent) 4 i r � a'� Date .
PERMIT #
B�UI�_�DING,PERMIT
0401-r4o
DATE 1-2o-,,) 'VALUATION $12. +00 LOT TRACT
JOB SITE
.ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PACT -10 HOWS
PANG FJCQ .'3
7' 564 A COUNTRY C. W.8 ,DRT F_, MT11-,11:
d '77564 A Ci7T,'sd'MY. MUD DRPI , ;3WTV, 3 13
PAIIA DE=7' CA 92 211
PA:I.;M 17E+SM(T CA 92211
(760)408.3493 C11LO 2953
USE OF PERMIT
POOL AMOK ISPA
F LP t Vj5f8A.RP%-I k'S SHALL BE YN PLACE AT 1'R&PI ASTf✓R..17NISPECTI011.
Pool" A,AFWOR, SPA 12,001+.00 I.J
R; 9 MhM lYID Codr 0F +CON91 lC'l."30
PIdW CHECK FEW 101.000.439.319 $97.75
c:cylaTIMICTION FEE 101-000-418-000 $135.00
`MRC.FLAN ° M, FEE'— POOL 101-000-421-000 $24,00
I., ?t"TRICAI, FSE ua POOL 101-0010-420-000 54500
P?.iIIs4BING FEE •- POOL 101.000.419.000 $2�J1l
SIM -TOTAL: CONTMtiMION AIT -0 PSS CHECK
$3111.75
- 1.R5344 FLIM -ICAO.; ril?133
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JtA � .. Ls31-LYOIT F—RES DUEJlfON
FAN 0 2004
I
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE .
BY r/' ��
DATE FINALED
INSPECTO
- .�
M
D
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR'
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
- / 'J .
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
^.Dater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
`
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
2,-7---/.
COMMENTS:
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)
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
Date 9/29/03 La Quinta, CA 92253
No. 25033 (760) 771-8515
Owner Northwest Southwest Deve. Inc.
4�J�FIFA�'y
,o
o
Q BERMUDA DUNES r
rn RANCHO MIRAGE t,�f
INDIAN WELLS
�..t, PALM DESERT ,y
Vn" LA QUINTA
tf4 INDIO `^
v O YJ
APN # 617-381-029
Address P O Box 1023 Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # 0309-106
Tract # Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 29 78720 Bottlebrush Drive
Unit 2
Unit 3
Unit 4
Unit 5
Comments
1823 Unit 6
Unit 7
Unit 8
Unit 9
Unit 10
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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,823 S.F. or $3,901.22 have been paid 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.
Fees Paid By CC/1st Bank - Dick Scott Check No. 69774
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Shpmn MCGilvrey Payment Recd $0.00
$3,901.22 Over/Under
Signature a44A4C
1-0�6
NOTICE: Pursuant to Government Code Section 66020(d)(1), tTWilserve 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 issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the Districtfs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting