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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 xp. Date
i
0- J3 CiiJ.3 9!
f
ate ' ' Signature of Contracto
OWNER -BUILDER DECLARATIO
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 q �y Policy No.
0,1,1 Fk.'S to S,FJ RV nN.i�Vb'1f
(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 assto'become subject to the
workers' compensation laws of California, and agleee that if Nhould become
subject to)he workers' compensation provisio s'of Section 3700 of -the �abor
Code, shall fo�thwith comply with thou pr vislor�s.
.,Date: /` 5 Applicant < /
Warning: Failure to secure Workers' Comensation 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 3
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 wit>ll_City, and State laws relating to the building
construction, and here�y authorize re•\esentatives of this City to enter upon
thZabove-mentioned proper for inspection purp ses. r
ature (Owner/ gen{t') / Date!' `✓'
BUILDING PERMIT
DATE/ A' VALUATION LOT
LOT
0160 CALLL HKISA
I
OWNER
, i). AUES . R 'C ems. V1.7LO." o4AE 1Prf
RG. BON,'! 7i6
1,A. QUINTA CA. 92253
USE OF PERMIT
PERMIT #
"0 6-024
13
APN
CONTRACTOR/DESIGNER/
TRACT 28CAO
649-210-00i
79-295 RAINC HO LH, QUINTA DR_
LA. QUiNTA CA 3225:
(-*('1771-194! CB?.0 29
ADD 1110N OF I WEST SUJ MT iia k4UiiSE LIIMD- E s
CONS'IRUC-1.1as (LCYF 1:4)
CUSTOM OONS,'i'12U t'1UN 272.00 Se
M., INIATIC DO Caff OF 100.0v
PERfiM FEV,
C;f:NS''1RIJC7111C.yxFIEE 1.01 -WO -418-o 0
PLANK CIRK-1 . RE
M -ON -439•M
Ni13(:i V41CAL FE -13
101-000-1+.'c14-000
525.57
l±L1;:C°"Ckt3t;AL FEE.
101•-000-42.0-000
.52
f?:[.Uj MINOR
101.-000-419nt?0i3
S.19-25
;1'!'1i,+i NO M0717()NF! E -
tOI-M-241-WO
$2.12
1ivTFRA;t1 UC"TUREFEE
225-000-4=$.3-34
$14.93
ART CN .PUBLIC 1'1.AGES - RESID 791-000-255-000
S52."
KIf1-3 C0"� ELL, C r0?�i� i iZ� Jt;'1 ��3� �rN�n 1'g..�1N r��I�tJ� $557.92
LESS PRE -C AID F.11217S $0,00
1'OTA L .1':1`;R1V IT FUS DUENOW &557.92
RECEIPT + I DATE I BY,.�� I DATE FINALED I INSPECTOR
M
INSPECTION RECORD
OPERATION.
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
G<
Ducts
Slab Grade
2
Return Air
Steel
Combustion Air
Roof Deck
102 _ 00W
Exhaust Fans
O.K. to Wrap
7 -.2-4
F.A.U..
Framing
Compressor
Insulation
_ 2
Vents
Fireplace P.L.
Griffis
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
69—
Heater Fina!
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
FWures .:`
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 6/14/99
No. 18882
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameT.D. Desert Development
APN # 649-210-003
Jurisdiction La Quinta
Permit #
No. 79-060 Street Calle Brisa Log #
City La Quinta Zip 92253 Study Area
Tract # 28640
Lot # 13 Square Footage 272
Type of Development Residential Addition
Comments
No. of Units 1
rtion of optional attached uest Suite to house under construction.
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:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in ,tbe amount of
1.93 X 272 or $ 524.96 the property listed above acid that building
permits and/or Certificates of Occupancy for this square footage in this proposed proiect`may now beiissued
Fees Paid By cc/PD National Bank/T.D. Desert Dev. - Judy Tciephoni,' "
Name on the check -
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $524.96
Check No. 75053
Signature
NOTICE: Pursuant OyAssembly 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 r6n 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.
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
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