0008-299 (AR)W
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W LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Cl:)pter 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 ENp. Date
Il"Ei�4f'4 , f c '8,12l2C
Date �f {' / Signature of Contractor
OWNER -BUILDER DECLARATION d
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 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 becom subject to the
workers' compensation laws of California, and agree that'if I Should become
subject to the workers' compensation provisions of Section 3,700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: , ' Applicant f � 1 , t.. _ .- - '✓ d
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 ate e"
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 repp esentatives of this City to enter upon
the above-mentioned property for•inspection purposes) I
Signature (Owner/Agent)' bate.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE ' /
APN
ADDRESS y
WAY
sA&fil7,049)?
OWNER
CONTRACTOR/DESIGNER/EN (NEER
3'Od T4s CPRCbn...P1: TTliJ�?,�.NCI C/o PR''�,1Mk3 .:>�t:
M'd? M9 CC3NS`i.RU6.`FY,l:L314'
7 6 - 7 If, CABRILL4. WAi'
79.2•952W3C1I63:,AQ1.1LNTA-D.R.
LA QXYDITA C.A. 92253
LAQUINTA CA 92253
f�°i�C117'i s ,10,� 1 CY3T�,' ; ��►�
USE OF PERMIT
RE M33M, MA
550 &Z Rt;}OM.fi1101'1"1ON &100SY. ;f'IATlO_GXAM.. M.APPMVLYJ
..PLANS
PO 01 A'Y'10 103.00 Sy
diMRYJ1n'MIM, COSM4+•d' F. rORV.4ROC1,1 N
- 44,175.00
f -TRAM SUMMARY
PLAN (011 WiM FEE101-MO-4397,318
CONSTROCTION M X, IM -000418-000 $.S91.00
M"ECHANICA1, PIS 101 -000-421 -000 $2139
X1.Y,f,' PjCAL YZ164, '101 -gas: 0-420-000 $54:40
S'{`ROTiXY'l+ OTION VEE • MAD 101-000-241-000 $4,42
yR 0
K.!"B� it3'PAT., C;C'+N'6Tlal..if�E,�OrT`CMM PLAIN C'.ICK4•i�a`�.�2
�j t` UMS PRE PAID FM
$0.00
15 2401
17 ��p'E(B�
UUN
RECEIPT
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DATE T
BY R �I
E
D INA D
INSPECTOR
E• 1
k
«r:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING-
Set Backs
Forms & Footings
APPROVALS
/ /'
�4� (�' (�
MECHANICAL APPROVALS
Underground Ducts
Ducts
Slab Grade
`
Return Air
Steel/�=
Combustion Air
Roof Deck
�'
Exhaust Fans
O.K. to Wrap
Framing
Insulation
_ _/ _
�
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
_ _ _
Final _�d�
BLOCKWAI,L APPROVALS
Final
y
POOL ,SPAS
Cr2�
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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)
Ijm
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 2/14/01
No.' 21659
Owner NameJim & Carol Plutecki c/o PrestNuksic
No. 78-715 Street Cabrillo Way
city La Quinta
Tract # Lot # 31
Type of Development Residential Addition
Comments
addition
APN # 646-420-007
Jurisdiction La Quinta
Zip 92253
Permit # 0008-299
Log #
Study Area
Square Footage 550
No. of Units 1
a cashier's check in the amount of $1,122.00 and $5.50 cash.
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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.05 X 550 or $ 1,127.50 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issped
Fees Paid By CC - Palm Desert National Bank - Judy Halpain Te',zp�one
Name on the check
Z.
By Dr. Doris Wilson
Superintendent
Fee collect4/exepted by Annette Barlow
Signature
Payment Received $1,127.50
Check No. 081887
40ME: Pursuant of Assembly 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
ibove 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)(e) 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
[SPECIAL INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑
❑ OTHER
JOB LOCATION
%
' `
REPORT SEQUENCE NO.
TYPE OF STRUCTUR
PE MIT NO,
DATE
DAY OF WEEK
TERIAL DESCRIP ION
a
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I PE TOR
HRS. CHARGED
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ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR
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COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS, SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
Vg/
SIGNA RE OF REGISTERED INSPECTOR
r6 �l X07030--��
DATE F R PORT REGISTER NUMBER