9807-149 (SFD)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
v+Aljl4 �r t+ i>'1�N
Date I �'�ignature of Contractor
OWNER -BUILDER DECLA N
I hereby affirm under penalty of perjury that.l 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&RC. 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.
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(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 I should become
subject to the workers' compensation rovisi ns of ection '3 00 of the Labor
Code, I s II fo with comply with tho�e pro siogsr
,bate: �pplicant
Warning: Failure to secure Workers' Compensate • n overage is unla7wfulandshall subject an employer to criminal penalties and civil fines up to $10
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 per 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.
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 res tatives of this City to enter upon h
the above-mentioned property f_or_ins ectio purpos.
Aignature (Owner/Agent)-==_ Dat I l � i
BUILDING PERMIT PERMIT980
149
DATE j//yty�LOT TRACT 'IS 1511
ADDRESS 49-.i 6.5 C..,tSJA !)i' L RiO
APN kl�Qo .b 9'L -jt i
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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Sj>r1'1c'r' r; nrr^y�,�r
P.6, BOX i 716
i9295 R Nt''NO i_J%. i;)UfN"1 A iis.
LA QU1N'"I A CA 9'2253
LA QUINTA Cil. 92:M
USE OF PERMIT
1`L" b'3 -A Pfs'ttivAT LXVS ''Ci i' 11V1 ii:t1>iW ktL< �i".�;. Vr Jil 1,v; VK
110(Al. Pi -AN CHECK FE1:Rl:dJiJ( ED 791/o KJPN %v UL •i't?'LE OF
Ah*.* PLAN 'TVPE
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RECEIPT "
DATEBY,
t;
DATE F LED
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
- 5
Exhaust Fans
O.K. to Wrap
- 2_
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_
2
POOLS_ - SPAS
SLOCKWALL
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
Q
Heater Final '
Water Piping
Plumbing Final
Plumbing Top Out
Equipment. Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- 7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) / -
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253'
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 9/3/99 APN # 646-332-021
No. 19276 Jurisdiction La Quinta
owner NameT. D. Desert Development
No. 49405 Street Casa Del Rio
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 416
Permit'#
Log #
Type of Development New Residential Addition
Comments
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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government. Code 53080 in the amount of
1.93 X 416 or $ 802.88 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/Palm Desert Nat. Bank/ Judy Telephone -
Name on the check
By Dr. Doris Wilson _
Superintendent
Fee:collected /exempted by
Signature
�.J
Sylvia Carrasco Payment Received $802.88
Check No. 80691
NOTICE:. Pursuant ot,Assemby Bill 3081 (CHAP 549, STATS. 19%) this will serve to notify you that the 90-dayapproval,perlod In which,you may protest the fees or other payment,ident�ed
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
oollecf 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