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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 of the Business and
Professionals Code, and my License is in full force and ffect.
License # Lic. Class \ Exp. Date
1
date f 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:
( ) 1 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 valub)ion is for $100.00 or less).
() I certify that in the performance of the worl(foAhich this permit is issued,
I shall not employ any person in any manners' as to become subject'to the
workers',compensation laws of California, andragree that if should become
subj to the workers' compensation provisions of Secy 3700 of the Labor
C e, I�h all forthwith comply with those`p visions.
ate: S`1.?'.��. Applicant , l
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 thisapplication 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.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 da s from date of issuance of such
permit, or cessation of work for 180will subject permit to cancellation.
Wt,�mentioned
l have read this applicatod state that the above information is
ree to comply with all Ci rand State laws relating to the building
and hereby authorize%�pres ntatives of this City to enter upon
property for�i6i a on purposes.
Signature (Owner/Agent)
Date -� �
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION S ! q.04141 flit LOT TRACT7733
JOB SITE
ADDRESS 79-9 1.5 '% ViA
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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USE OF PERMIT
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RECEIPT
DATE
BY J
DATE.FINALED
INSPECTOR
%-.J
INSPECTION PECOO RD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPL .
BULDING APPROVALS
MECHANN CAL 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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
SLOCI WALLle APPROVALS ALS
POOLS a SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBHG 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
Final
Utility Notice (Gas)
E L ECT=AL 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:
Date 417/03
No. 24295
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School. District
4.7950 Dune Palms Road:
La Quinta, CA 92253
(760) 771-8515
q��n�U7l7��0
BERMUDA DUNES r
C,n RANCHO MIRAGE d
t�A INDIAN WELLS
PALM DESERT y
LA DUINTA
%INDIO ��
0
Owner
M/M Ted Burchell
APN #
646-333-005
Address 78-915 Casa Del Rio
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit#
0304-012
Tract #
25154
Study Area
Type
Residential.Addition
No. of Units
1
Lot'# No. Street
S.F.
Lot # No.
Street S.F.
Unit 1
91 78915 Casa Del Rio
375 Unit 6
Unita
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments Casita
At the present time, the Desert Sands Unified School Distdct:does not coiled 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:
Detached Accessory Structure
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 $2.14 X 375 S.F. or $802.50 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 CC/Wells Fargo Bank - Mike Kirk Check No. 0737704378
Flame on the check Telephone
Funding 'Residential'
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey $802.50®
Payment, Recd OvedUnder
t
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 perm# for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authoriredto collect them on the; Districtrs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy- ApplicantlReceipt Copy-- Accounting