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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
Professipnals Code, and my License is in full force and effect: -
License # Lic. Class Exp. Date
691405 13 13WO
Zate - f Signature of Contractor '�'--'C A1_- !4
1
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: j
( ) 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). �111 .
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under$ penaltylof 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.
(Y) 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 ST Policy No. f C A
eY A Ci L }i�`r ,}f�T0 %J
(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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
C�de�l:shall.`7 forthwith comply with those provisions.
"tate: t 1 `i �' Applicant . i 'c'r� <..-. �1C !{ • 'i' x-w--�^•,,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00,000, 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.rl agree to comply with all City, and State laws relating to the building
k construction, and hereby authorize representatives of this City to enter upon
th %above-mentioned property for inspeect purposes. i
nature (Owner/Agent) ,-,t" ', { �- "-' 'y Date T l 7
BUILDING PERMIT PERMIT���-iy77 CONTROL#
DATE _.VALUATION��(� LOT TRACT 8181
JOB SITE
49-M C ACIIF.:LLA DR
ADDRESS
OxWNER
CONTRACTOR / DESIGNER / ENGINEER
V W .BRZOZONNrSK1
CLASSIC BUILDERS INC
INDIAN tiV1;I,t.S CA 92210
CB1_# 14999
USE OF PERMIT
RESIDENnAt, AMMON
ADDI z !ON OF 2 CL01SEY S AND V. -A!090, OF TWO i -:a' IiS T fNG BAT.I1i 00M.S
262SF
C:`- JS rvi. CoNi ir'�1T+<:"I'. 0 Ni 262.00 SIF
�+�1�i.a l� 'OST OF W14'vISTRi.��.i ON.'
20.4ili✓A0
MRINI 'I' PEE SiJMAqAlr V
111LANC.kiL:4X ViEE lti3.-(1O#i-439-31� $1dQ.40
C,0N. fRkTC." I0N1 FEE, 101-000-418-000 ;21f.fN1
1 ECHANICr'1i,Vff? 101-000-421-000 $34.50
&EC'CRICAL FT,C 101-004-420-000 $34167
PLUf',41i1NG k'EE. 101 -000 -419 -OW $75.00
STRONQ1\4C:C10NIP ` -RESID 101-000-941.-000 $2.04
GRADING 111M 101--000-423-000 620-00
a
f`
SUS -'f TOT.A C bNl"Mt u�' ION AND PLAN CHFCk
4r"_. 01
1.'¢fJ�A' I L SS PRE -PAID FEES
PA{�pp
tI C: J
$0.00
SEP 17 TO TALPERA e^i'!'41✓ SDUE1+aOW
$522.61.
kill .7
�ECEIPT
DATE i
1
BY '
DATE FINALED
INSPECTOR
INSPECTION RECORD
• OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
r BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
f
Return Air
Steel
Combustion .Air
Roof Deck
_ _
Exhaust Fans
O.K to Wrap
F.A.U.
Framing O,C,(�
Q
Compressor
Insulation
��/r 1
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
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
h
Final
Utility Notice (Perm)
COMMENTS:
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY O
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION
_aOC> 66 LA
Q u � V.T�v CA
REPORT SEQUENCE NO.
TYPE OF STRU TUBE ^ 'a
'IL(�J( Z�
PERMIT NO.
DATE �_L 1 ,.,)
LV
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
/ rLL
INSP TOR`1
HRS. CHARGED
ENGINEER
^
ILS
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERALGI (� IRJU l 1 e
CONTRACTOR Q /`
SUB I
CONTRACTOR
_ ,Q bq
(�
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OAeeL En
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G[.Us e;;t- xeev%-
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COPY SENT TO CLIENT ❑
ONT INUED ON NE%T P -
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
St;A URO REGIST DY�ECT ot-7
ATE OF REPORT REGISTER NUMBER
Notice:
Document Cannot Be Duplicated
Date 9/10/98
No. 17673
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameF W Brzozowski
No. 49-200 Street Coachella Drive
APN # Not available
Jurisdiction La Quinta
Permit #
Log #
City La Quinta zip 92253 Study Area
Tract # Lot # ' Square Footage 262
Type of Development Residential Addition
Comments
Addition of 2 closets and remodel of two existing bathrooms.
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the,amount of
0.00 X 262 or $ 0.00 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 B N/A - Classic Builders Inc. T '; -
Y Telephone•
Name on the check .�
By Dr. Doris Wilson ^ `-
Superintendent
Fee collected /exempted by Juanita Green
Signature
Exempt
Check No. N/A
$0.00
NOTICE: Pursuant of Ass ly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run frorlthe 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
collect 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
Commun.i ty Azzoc-fat-ton `� ~
P. 0. Box 162 '
La Quinta Ca 92253
Telephone: 760/564-2177 FAX: 760/5644882
September 11, 1998
Planning Department
CITY OF LA QUINTA
Post Office Box 1504
La Quinta CA 92253
RE: 49-200 Coachella Drive
Ladies and Gentlemen:
Please be advised that the residence of Fred W. and Le Verne Brozozowski is
not a part of the La Quinta Golf Estates Community Association. Although they
live within the boundaries of our Association, they do not come under the
auspices of our CC&Rs.
If .you have any questions, please contact the office.
Yours truly,
Anne Tuttle
Association Manager