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LICENSED CONTRACTOR DECLARATION
4 reby affirm under penalty of perjury that I am licensed under provisions of
C%pter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force andjeffect.
License # Lic. Classr Exp. Date
Date 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:
( ) 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.
Sa>,0'; .. t,•<,t) tiff? ! 79-+5
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of thAork 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 Californi6;land agree that if I should become
,subject to the workers' compensation provisions of Section 3700 of the Labor
Code,a shall forthwith comply with those provisions.
Date: ' ` z Applicant �!f
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. µ ,,
IMPORTANT Application is hereby made to the Director of Balding 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. 1
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�repfresentatives of this City to enter upon
the above-mentioned property
yffor/I�nspection purposes. t
Signature (Owner/Agent) 1� Y Date' 0 C I'�
' et
BUILDING PERMIT
DATE VALUATION -,3K�f#tiib.fi>fl LOT
PERMIT # CONTROL #
701-014 5871
TRACT
JUB SITE
ADDRESS 48-56.] C A.ixIS RANO Wi i` APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
44R -_V5 CAPISTRANC.) Vkfd1Y 74027 10f`31:D.t IVIi> 1/A
€A l"KA TA. CA 92253 PAUNT €lF81AT Clea 022(4)
060 NO _9000 CIPM�# 155
USE OF PERMIT
f)O tl:u
POU ,AM.) SPA C -N - L. V
15,00.00 LS
RECEIPT I DATE
3E-�t;-€?l, DR!, $0.00
DATE FINALED I INSPECTOR
PLAfd C; HFIC'I; lrF
€i! f�t3f1!t.�?: ! -31€t
ff13. lrt
r 01(-J,t'FR(ft`r]r 14 i;
1tlf.{3€tf).�lxk-�!(dl
! 4lv' iK1
NVIC31M44CAL FEE __ VIL )KI
S .`1.(*
FEE -- lJQ(.:; .
1101-00042(000
PLt1Ml Ni G RK -_ MY -A,.
1.01-000-419-01A
RECEIPT I DATE
3E-�t;-€?l, DR!, $0.00
DATE FINALED I 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
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
L
Set Backs
Electric Bond
2
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
L
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:
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 # 646-390-015
No. 14150 Jurisdiction La Quinta
Owner Name T.D. Desert Development
No. 48570
City La Quinta
Tract # 27840
Type of Development
Comments
Street Capistrano Way
Lot # 123
Single Family Residence
Permit #
Log #
Zip 92253 Study Area 123
Square Footage 2572
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.°` y¢
Fees Paid By T.D. Desert Development Telephone X771-1 94.1
Name on the check _
By Dolores A. Ballesteros r
Superintendent
Fee collected /exempted by Pauline Pearson
Signature Q'6t i a Q nn o \: utJIACV01-
Payment Received
Check No.
7881
$4,423.84
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