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LICENSED CONTRACTOR DECLARATION
I hereby affirm 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. 674074 B11M1/97
License # / I Lic. Class "Exp. Date
Date ` I ,Signatureofl;ontractor t t 1
OWNER -BUILDER DECLARATIO f
I hereby affirm 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 sect�pjQq dYot&e completed if the permit valuation is1fp9;J,90.00 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 wor'kers' compensation provisions of Section 3700 of the Labor
Code, I sh f forthwcomply with thosemprovisions.
Date: �-�� /.0 Applicant I ... .. -
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 cancellations
I certify that I have read this application and state that the above informatidrV 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 jfor inspe,c�tion purposes. f -
Signature (Owner/Agent)'"> / Date�lFI '4 y'
ALC ' BUIL DING PERMIT PERMIT960.11i71i `
DATE VALUATION S1185..1581.M LOT 129 TRACT 27540
JOB SITE ADDRESS 49-5110 CAPISTRANO WAX' APN 645-390-021
OWNER CONTRACTOR
SPARKS CON' ZrMlIC CION
T.D. DESERT DEVELOPMENT LP 79-295 KINNCIM f,' QTJf ,9'A DR.
.P.O. BOX 1716 LA. QUINTIC CA, 92253
LA QUINT A CA 96253 (61gi771-19411 CBL# 2996
,619 771.-1941 DESIGNER/ENGINEER
USE OF
RANCHO LA QUINIA
'ITIRRAZA PL &N 1
DESCRIPTI
CUSTOM CONS11RUCTIVN 2,2..:1.00 LF
PORC 41PATTO 170.00 SF
GARAGE/CARINORT 4W00 317
TINL=l'tED COST OF CONSTR:UC'>�i'
N
PERMIT FEE SUMMARY
Pj.AN(';FtEQ111 •r.F1_,
$ 74
t�OAf:31721JG"1"101+l T?l'�;
101 -000 -418 -ON
$940.
MWIIANICAL REZ,
101-1100-421-040
$98
F:LEC'IVJCAL FEE
101-000-420-000
$167
P1.1 %fnrNt'1 T -1:'t?
1()1. -11(1(1-4i 9.000
$142
STONG A10TIONF X - P.1:s.S.i11'_}
100,%%-241-000
$18
01AUIN0 FIM
101-000-42.1-000
$20
1NF1tr1,STRUC1'L RE !~ 1-6
125.0{)1}-443-342
$4,124
ART IN :POBLIf; :PLAC'YS - RFS11r 101-(iWL'5.000
$213
.54
z50
,$I)
.81
Jm
.56
.100
.71
,95
1SS,':4ap.50
.S't1f3A"lri"'ii L CONSTttUC',1'ION AND PLAN CHECK $61.500.57
LESS PRE -PAID FUS $0.00
1 a
�Ee
TO'!: A.I. PnM15<1C1f 'FEES i?1v C INOW $611500.57
31996 z .
RECEIPT -I'DATE IBY
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I I
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
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
Fina ,
LfflIAj Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 2/13/96
No. 14156
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name T. D. Desert Development
No. 48510
City La Quinta
Street Capistrano Way
APN # 646-390-021
Jurisdiction La Quinta .
zip 92253
Permit #
Log #
Study Area 123
Tract # 27840 Lot # 129 Square Footage 2231
Type of Development Single Family Residence No. of Units 1
Comments
By
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 1.72 X 2,231 or $3,837.32
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.
- L
Fees Paid By T.D. Desert Devlopment _ Teleohone- 7714941
Name on the check
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,837.32
Check No. 7881
Signature c t\� .� a .Q A nn VcC XVV\-,
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