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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)3 of the Business and
Professionals Code, and my License is in full force and,effect.
License # Lic. Class Exp. Date
656(28 C—" I.0131198
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).
( ) 1, 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.
,,TATH141,ti'1') ii 16 447. OfI.t;1.0, -
(This section need not be completed if the p
( ) I certify that in the performance of the
I shall not employ any person in any man
workers' compensation laws of California,
subjdct to the workers' compensation proy
CAe, I shall forthwith comply with those,pl
ate: ' '`� �+ ` Applicant ✓
valuation is for $100.00 or less).
for which this permit is issued,
o as to become subject to the
agree that if I should become
of Section 3700 of the Labor
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 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
thw6bove-mentioned property for,inspection purposes.
X119nature (Owner/Agent) = r ft Date r%
BUILDING PERMIT
DATE 2(z.4t97 VALUATION $l):R,Dilti.tN! LOT
PERMIT # CONTROL #
97412 -USI► TRACT 4732
JOB ADDRESS 48 -SO CA1*J.S 1'RAN0 WAV APN
OWNER{{ r"1111
! ��{{ CONTRACTOR /(DESIGNER /tENGINEER L
�Pk
NHA
49i*40 CAPISTRANO WAY 74-7215 JONI MME, i#A
LA QU!N'1'}\ , CA 92253 PA�I,M DQSI;RT CA 92.20)
fh! 140-90(111 r'11111f 355
USE OF PERMIT
II X'ai.
itiflf. ANt. SPA ONLY
POOL ANDiGhl SPA
15,000.41 LS
1.'.4MMA'fED COST Of WOOS" $ add K -71 0N
vs,oao.00
PLAN O'111XX Ft+'
101- VO -439 -:alts
s 1N rilON i'Ri,
101-()O)-41ff.(ifll)
1y1F�;!,itli
I411i'CHANIC' ii, f i:+: -- i°rJFJI.
tU1.0[10- !Zi- •0
'r':�t.{?+)
—420-000
10 140-420-000
S�iti.tiU
1°i,i114)i11f+f<7);{%t; _'j,cxlr.
10140).41940)
52
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t11l=11�1'A1.,fi't�j�3S'�'Rtxi:1)CIN A1�d! 1'I.t1N C:II:GI:.r
UISS ME-P,li.tt) FEt S
UYKAL PERNIff PEWS' 01%, NOW
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
S363.30
SOLO()
$363.30
INSPECTION RECORD
OPERATION T77;ATE
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final 1 5 - —
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond — G
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
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:
t
Notice:
Document Cannot Be Duplicated
Date 2/13/96
No. 14152
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 48550
city La Quinta
Street Capistrano Way
APN # 646-390-017
Jurisdiction La Quinta
Permit #
zip 92253
Log #
Study Area 123
Tract # 27840 Lot # 125 Square Footage 2572
Type of Development Single Family Residence
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 1.72 x 2,572 or $ 4,423.84
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 T.D. Desert Developoment
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
_ Telephone 7771-1941
Payment Received $4,423.84
Check No. 7881
Signature lye , a u nn o L11 a A �
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