9602-013 (SFD)CA LICENSED CONTRACTOR DECLARATION
N I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
o^ C) Lo License is in full force and effect. 674074 13 7/31/97
r_ LU r License #�, / Lic. Class _ Exp. Date
Z ^ Date ?. h l /Pc -. Signatureof Contractor
c'o P OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
Cl following reason:
Z ( ) 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
Cl)
Date Signature of Owner
N
WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
C) Z () I have and will maintain a certificate of consent to self -insure for workers'
�O cc compensation, as provided for by Section 3700 of the Labor Code, for the
X LLI LL. performance of the work for which this permit is issued.
p J J () I have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn Carrier Policy No.
'? Z (This secfionAregr1'n�,gt4oe completed if the permit valuationys1f99$),90.00 or less).
N a() I certify that in the performance of the work for which this permit is issued,
C3 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 workers' compensation provisions of Section"3700�of the Labor
Code, I shalllforthwith comply with those provisions.
Date: �? , .� ' �rt/.eApplicant �
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify /
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such,
permit, or cessation of work for 180 days will subject permit to cancellations
I certify that I have read this application and state that the above informationis
s
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize represergtatives of this City to enter upon the
• above-mentioned property for inspection puiposes.
Signature (owner/Agent) ! �- Date C✓
ALCM
BUILDING PERMIT
PERMIT46f),-f),,
DATE 1 /g°i1
VALUATION 14D TRACT . 164V
J08 SITE ADDRESS49-550A �T.� RANO WAY t.
APN 644.3XI.017
OWNER
CONTRACTOR
SP,AJAKS CONTCR,UG'iI N
`t',I7, DESE..RX 1;?FVi:7.OMF-' NT Lig
101 WA.LS'° N RRUDGIN RD NO.
RG. BOX 1716
LA Q ►:WTA CA 9.2253
LA. Ql;liz TA. CA 92253
(At�)7714941 C L# 2996'
DESIGNER/ENGINEER
USE OF PERNt (;i, E.P ' .1. M L .. A U,
RAN{,"F IO LA. QU [N'rA
'J'ERRAZA. PLAN 2
FEE DESCRIPTION
FEES
C1PSTOMa)NV1L0'il1.0N 2,572.00 Sr
PORCIVIPATIO 115.00 SE
CARAGWCARPORT 6W00 SP
E.STI1VdATED COST Off' CONS'm4Jf;'rioN
215,3114..30
PERAWFEE 9UNIMA.RY
P.► AJ4 CHECK FTFM 101-000-439-:315 S8754A6
GQ"NS`Iauc rioN nc 101-000»41$-000 $1,045,60
fvd-,(" 4AN.ICAL IM 101-000-42i-000 $142.50
EeLEC RICAL "FEE 101-000-420,000 5197,22
PLITl1MING F E 101-000-419-000 SIRS -00
STONG 1b M,70N FEE - RESID 101-000-241-000 $21.53
GRADING WME 101.000-423-000 S20M
1NFRASTRUCTURE.FEF 225-000-443-342 54,81C►,1h
P11KISE, MAN 101-000-441-345
ART JN PUBLIC PLACES ,'RE -ac 701-000-255-000
,Q "A1. CONISTRUCMN AND MAN CHECK
$7,617.66
�1 IESS :PRC-PAID''FE9S
50.00
F�B
2<3TOTAL IEi11IVIT FRES DUE, NOW
$7,617."
996
'O
RECEIPT
DATE
BY
DATE RNALED
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
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 df
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 Pibg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines sa'
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Connection
Encapsulation
s Piping
Gas Test
Appliances
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 - -9c AWE
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 2/13/96 APN #
No. 14134 Jurisdiction La Quinta
Owner Name T.D. Desert Development
No. 48555 Street Capistrano Way
Cit, La Quinta zip 92253
Tract # 27840
Type of Development
Comments
By
Lot# 111
Single Family Residence
646-390-003
Permit #
Log #
Study Area 123
Square Footage 2231
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 2,231 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.
Fees Paid By T.D. Desert Development Telephone 771`1,941
Name on the check —
Dolores A. Ballesteros
Superintendent �� : L
Fee collected /exempted by Pauline Pearson Payment Received $3,837.32
Signature PaA,
Check No. 7881
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