9707-055 (RER)F1
LICENSED CONTRACTOR DECLARATION
-.44iereby 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
z
Date 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
Xmpensation, 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).
/O I am exempt under Section B&P:C:*for this reason
Date % .-'+ Signature of Owne ,,7-
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.
(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:' .114,' k7 Applicant �_ 1 /2';Z r
/ to secure Workers' Compensation coverage is unlawful and
Warning: Fail -
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., 'f
1. Each person upon whose behalf this application is made & each pbrson 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 for. inspection purppo;Llate
Signature (Owner/Agent]'`
BUILDING PERMIT PERMIT# V Y CONTROL# .;
5.5 0'2
DATE 1' _I 7VALUATION �'� LOT TRACT
ADDRESS 44-445 C1 MNO � AVANDA JOB SITE f
APN 604-193.016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KENNETH K & RUiiUNI THE PHILLIPS
0% NER ! BLt1t..DER
44445 CAM(NO LA.VAANDA
LA Q)LllWA CA 92253
C1SLl�
r
USE OF PERMIT
K NIO D
GAt ACE cowPiRsiotN -i rn 5. t, . `r AA4 Ly Room.
BONUSROOM ?20.0U SP
r
E-STTMATE.D COVE OV CONSY RUCTI N
PERMIT FEE SUMIN' ��RY
PLAN CHECK FEE 101-000-=139-318 5611,35
CONSTMUC1'ION FEE 101-000-418-0011
ti1EC11AtJ1CA1. 101-800421-000 311W
11.EC MCAL FER 101-000-420-000 515.00
STOW NKITION FTX, - P SITS 1At-000-241-000 S.76
A
Y +g
j B_1f 'r.AL CONS"rRUC'I'1ON AND PLAN CHEC
$194,11.
PA[�
LESS Pi21;4AJ0 R_.,%S
V1010
JUL 15 1997 TOTAL PERMIT FEES Df,T1':1VOW
$1.94.11
�cV OF MTA.
RECEIPT
DATE
y
BY �(
DATE FINALED
INSPECTOR
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
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 APP OVALS
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
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:
Ok-
Lc
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 7/15/97
No. 15796
Owner Name Kenneth & Ruthann Phillips
APN # 604-193-016
Jurisdiction La Quints
Permit #
No. 44445 Street Camino Lavanda Log #
City La Quinta zip 92253 Study Area 233
Tract # Lot # Square Footage 220
Type of Development Residential Addition No. of Units 1
Comments
atm y room
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 220 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 slow be issued
Fees Paid By n/a ` Telephone 360-0068
Name on the check
By , Dr. Doris Wilson
Superintendent
Fee collected /exempted by
Signature
Pauline Pearson
Exempt $0.00
Check No. n/a
IOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9D -day approval period in which you may protest the fees or other payment identified
bove 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
ollect 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