9904-078 (RPL)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
Date 4111 211, 6 Signature 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).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
o Z 1 hereby affirm under penalty of perjury one of the following declarations:
LO 01
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W !:� compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
00 -3;aii*'i :5 {'i:v Bili==i-i!�lti+i 3t4i�
J
(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 sh�ld become
subject to the workers' compensation provisions of Section •0'0 of the Labor
Code, I shall'forthwith comply with those provisions.
Date: ,, / 144 Applicant lam'"
Warning: Failure to secure Workers% ompensation 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
J..Z. & 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 inspection urp
oses.. y
Signature (Owner/Agent) Date �- ��•' /
BUILDING PERMIT PERMI"(14-I)1K
DATE VALUATION.'ii,i�{►Il.i>!i LOT `1Q TRACT
ADDRESS t /9-1311, l.t�,LLF I�HUSA JOB SITE
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i.ii` l)i11.11,S 'A
,ii�iNA ,P,"
i1c, B001k, i73u
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I.A. t,)iJINTA (_,A �)2 2.►3
PALM 1.11 81iRI' (2A 91221(4)
f7ft4)1:+lfi 1'tltitl t1#il.11
USE OF PERMIT
POol,JNNj.iiiJK
PC"__#LM, 'A & 13AV, A),AI NISVIIAkiti%.it:: W iALL W', NAT PI i-.i1LiQ'f F1<
P001, T 1411!`1,, R i)PA 19,800Y) 44V
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91ffVIVII'A1.Cl)NN"Vk1lfff'10N ANO PLAN t'°fJVCIAC
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LE'" TIRE r"'100 prir
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'i'C)`;f'AJ, ?'[,*,RIMU t+b'IEN DUE NtAV
54422.711
RECEIPT 1' DATE
BY 1,7:
DA FINALED
INSPEC R
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &•Footings
Ducts
Slab Grade
ReturnAir
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Flaming
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
-
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
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
Fixtures .
Main Service
Sub Panels '
Exterior Receptacles
G.F.I. .
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
01/16/2003 12:26 760777_
�7.
X
01/01
r Bin H 1 City of La Q uin ra
1 . 34- ` Building sr Safery Division
Permit 1 "1 P.O. Box 1504, 78-495 Calle Tampico
1
LO l'J La Quinra, CA 92253 - (760) 777.7012
Building Permit Application and Tracking Sheet
ProjcctAddress:7 1—( 30 G -z I Ie 9 c ( SGL wner's Namc:'( GJ�S�JIT Jul-G(N4y7= CP
A. P. Number: (o < Z/ O r- 00 3.
Legal bescription:7/AtC'( ?,9&4-0 LO,T ZO
Contractor:�9��-KS 6ENST�{i�
Cin. ST. Zi r` ., • . — G4 C� Z Z 7 3
ona,�C,���
Address: ��� ( -.i (CD.
Project Description:
/ Q
City, ST; Zip: L ! cJi 77,�
TelePon•7 hz
�
a L Q �t
State Lic. -9 : (, 7 q C Cit\ Lic. n: �i `Z
Arch.. Engr.. Dcsiener:
phi C
Address:
GtL/72LL�/�
City. ST. Zip:
. r Al-
12-
Tele hone:
P
Lic. r:
Name of Contact Person: A/1--' i 4,ir��—�
Con truction Tv Occupancy: c:
s , p
Pro)cn ne(circle one): Add'n Alter RePait D c
tState
..
Sq. Ft.:3�( �j N Stories: ;� Units:
Telephone i� or Contac; Person: r7l O)?%/_r C
L•stimoted Value of Proieci:'*g C00
APPLICANT: DO NOT WRITE BELOW THIS LINE
# Submittal Req'd Recd TR.kCKING PERMIT FEES
Plan Sets
Plan Check submitted firm
Arnow
Structural Calcs.
Reviewed. ready for corrections Plan .heck epvsit
Truss Cates.
Called Contact Person Check Balance
Title 19 Calcs.
Plans picked up Cann, tion
Rood plain plan
Plans resubmitted n1e apical
Grading plan
_'"� Rei iet+. rcadr f come ions/issu ectrical
Subcootactor List
Called Contact Pc son Plumbing
Grant Deed
Plans picked up
S.M.,
H.O.A. Approval
Plans resubmitted
IN HOUSE:.
34 Revics%. read' for correctionsrissue Dr*%,I Cr I Fpact FCC
Planning Approval
Called Contact Person A.1. P.
Pub. '%N'ks. Appy
Date of permit issue
School Fees
lots) Pc it Fes
Date
No.
Owner
Address
City
Tract #
Type
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
4/16/04 La Quinta, CA 92253
25800 (760) 771-8515
Bob & Carol Hewlett
79-130 Calle Brisa
La Quinta Zip
Residential Addition
Q BERMUDA DUNES
DO RANCHO MIRAGE Cf
INDIAN WELLS 'ter
PALM DESERT ,y
LA QUINTA
IN,�
��0 y:
0
APN # 649-450-002
Jurisdiction La Quinta
Permit #
Study Area
No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 79130 Calle Brisa 378 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments Detached Guest House
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 $2.24 X 378 S.F. or $846.72 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 Palm Desert Nat'l Bank -Judy Halpain Check No. 088167
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon MCGilvrey Payment Recd
$846.72 Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 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 District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
MEMORANDUM
To: Greg Butler, Building & Safety Manager T . o CDD: 3 - 10-04
From: 4V, lvrs 131r --planning MU191toy, e169
Building Permit Release-'
(this is an approval to issue a Building Permit)
The Community Development Department has reviewed the following project':.
Description:
Address or general location:
X, e
-,0,7q -
APN and/or legal description:
The Community Development Department finds that:
... issuance Of this Building Permit does not require Community
Development Department approval.
-issuance Of this Building Permit is approved by the Community
Development Department.
`07
Planning
" D'.
Date
i
S ^7 rru Y1,Z -310 4
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1
1
3.17_'
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