0201-207 (AR)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
343335 D, C36 CWFUC
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
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.
(s) 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 IRTATR FIRM) Policy No. 229-910014,4157
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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.E)
2. Any permit issued as a result of this application becomes null and void. ifV�
work is not commenced within 180 days from date of issuance of su861.
permit, or cessation of work for 180 days will subject permit to cancellatio4
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 purposes. i +
r
Signature (Owner/Agent) GNB'%- -w �J' ^'""" Date �tf�
BUILDING PERMIT PERMITp
iD°�1..2.c3`7
DATE d VALUATIONnw LOT 45 TRACT '24517
JOB SITE
ADDRESS 79-245 CAMINO DME, C RK)
APN MW 1,12-027
OWNER
CONTRACTOR / DESIGNER / EN (NEER
79245 0R- 0
54310 AV12Tl�' A,R)tC.r:2:
LA QUIMM. CA 92253
LA < CANT A CM 92253
3
1
07603564.4 fi4? M14 2051
USE OF PERMIT
(41•,0 s.i.) ' C'ai 'l`}Sf 1,aF .�� 7'ft►'iw/ coy i"iC ( 44
s, r;)
TRAM Mr!59'TRUfM0N 416,OD SP
4 :i11,'HSTRUCTICN'1T`1 � 101-000-418000
ktd.AN t f-lWX ME, 1.01.000-439.318
fatly��E:fkfi(�py1p•1�1iCpAL Rg 101-000-421-000
0 21-'U}0♦/L��
g1-00�{l-
�.T✓l.I'w•�? B'414d1IJ 9• d�l'? :I 18 d ^iy�LltY"ul.Ifif]-�/�1L' NJ Y. �E3
tjJ UMPI.l"t1 RE 301-00.0.4.19.000 14010
S'rRO10.,MO'r1rjN 9Yitr , RESID 101-000-241-000 $2.43
ClR,t�i�li�t��k'1�,i� - 1U;�QCtp>4��••f)iit� R3Ci,Q0
:4
Out), .1W.-WL-CeDN' STRU =011 AND.M.Abr 01TI K
.$60031
L ITZE-PAM FRES
$0.00
FEB 0 % 2002
WY ORAQUINT
RECEIPT
DATE
DAT FI ALED
INSPECTOR
r
'HP!f
INSPECTION RECORD
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
_
zg
F.A.U.
Framing
-
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
z
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final -�ZL
BLOCKWALL APPROVALS
Final
Steel
POOLS - SPAS
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
— ,— 0 2
Encapsulation
Gas Piping
Gas Test
_y
Appliances
Final
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)
COMMENTS:
-
M
-17
Bin #
0;0/-
City of La Quintd
Bulift at Safety Division '
P.O. Box 1504, 78.49S Cafle Tampico
La Quinta, CA 922S3 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: MiAld bE�,oCa40wner 'sName-)�)Rk A40['rrl V, M/
712 q�' MA _T
P-6'6 C
A. P. Number: Ec C-4" 1�
(aQ 0 2-7 -4Address: _q2-qLe,4AJ(JV J)&L c) P, 0
Legal Description: City, ST, Zip: L) I A) -rA
Contractor: Telephone:
Address: P. C, C) x ZZ Project Description:
City. ST, Zip: L,Ui N TA OAq ZZ.S 3 41-7- c4 A , 'D j��crFfg TIW14
Teiephone:;76r) -:5-� 14 q -7vt
69
State Lic. 9
Citv Lic. *.'2-o5J
Arch., Engr., Designer:
Address:
City. ST, Zip: x/657, 7,41 7-d 225-
Telephone: riidn TvnL-' ane
UP \'
===Zoe
State Lic. 0: Project itype (circle one): New Add'n AIteT Repair Dcmo
0 Name of Contact Person: M11rJZL/1AJ J-0 �D 4N Sq. Ft.: L-1 1 79 Stories: q Units:
P Telephone# of Contact Person: 5144-444N7 1. Estimated Valdeof Project: 'Z- ,000
01 APPLICANT. DO NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Rec'd
TRACKING PERMIT FEES
3
Plan Sets A. 44'W'/-
2t
Plan Check submitted el7v
-P
pt item
Amount
Structural Ca)cs.
Reviewed, ready for corrections
40ff/vi Yllan Check Deposit
Truss CaIcs.
Called Contact Person
Ian Check Balance
-7
Title 24 C21 CS.
Plans picked 'up
Construction •
Flood plain plan
Plans resubmitted
-Mechanical •
Grading plan
2" Review, ready for correcli
Electrical 0
Subcontactor List
I
Called Contact Person
Plumbing •
Grant Deed
Plans picked up
SAII.I.
H.O.A. Approval
Plans resubmitted
Grading 6
IN HOUSE-.-
" Review, ready for correcti s issue
Developer Impact Fee
Planning Approval
Call Contact Person
A.I.P.P.
Pub. Wks. Appr
r/.,c of permit issue
W7 S
School Fees
za:F"i aVrM FT
dl, I
�rz
I A
6VA I ff/OA
I Total Permit Fees
Notice:
Document Cannot Be Duplicated
Date 2/7/02
No. 22921
owner NameKirk Moffitt
No. 79-245
city La Quinta
Desert Sands -Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Street Camino Del Oro
Tract # 24517 Lot # 45
Type of Development Residential Addition
Comments
Bedroom & Bath 416 s.f.
APN # 604-192-027
Jurisdiction La Ouinta
Permit # 0201-207
Log #
Zip 92253 Study Area
Square Footage 416
No. of Units 1
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 416 or $ 0.00 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
r
Fees Paid By Exempt - Marvin Jordan Telephone 760-564-4447.
Name on the check ? ,
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Nicola Wong Exempt $0.00 'r
\ Check No. -
Signature
NOTICE: Pursuant to Assembly Bill 3081 (CHAP 549, STATS. 1 6) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment idented
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 DistrictCs)(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