9609-124 (SFD)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
i>.+V,JIM it
ate f? .( Signature of Contractor r 7
1 i
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.
V) 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.
"'TAT LIT*40
(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 agreefth t if I should become
subject to the workers' compensatiorn provisions of Section 3700,of the Labor
Code, I shall forthwith comply wit ll those provlslonV
..•Ll r�.
Applicant 1 l� .nf'� ._• �-^`
4,V
Warning: Failure to secure Worke. ' 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
applluallul 1.
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
the above-mentioned property for inspection purposes.
Signature (Owner/Age t) ' a � . /Date
BUILDINGPERMIT PERMIT# CONTROL#
4440
DATVALUATION.t_�,"i���.t�t LOT t -� TRACT
E
JOB SITE
ADDRESS .S�� �kwi c."xi'I'le, ()U. CU
APN
J
OWNER
CONTRACTOR / DESIGNER / ENGINEER
NAIN101',L AND t.')t,, VIA A('(1Kt'N
(101101NI IL CON111"i'tr1.l111110N
66-213 1.11.011WAY go
77836 AV EWRM Nt0%N'Ml4hbk d
'T°l°>rE.RMAJ, CA W?74
L.A. QtN'1'A CA
USE OF PERMIT
`tf`1t4t�ts 1.�71�t.tLi f.LWf:l.f.ft��-,
)h.0- tlfikitil) f DOES N01' Dx�C4`l li.Llls:ltf..t>E'►s, WALL OR
OAt2E1f1>v't�'Ak1�t)t'i' w•Jt.tlf) ��
VNf:.1 ATED ("ii,nt OF CON4TRl)c`ii. IN
174.74.00
('ON,*- ,R1ICTION I++ 1()1-190,104-000 S"AM"to
Vt,gt� t"111..{'p 1 i"/t'. Iflla({I7f1 4�1.t1{i t7iig1+�Q
h -If --,`f 1AMiCtVI, ) ;f.(i.> . . i 6 1 �9811J
1.1, Yt'I*,W If 'iv, 4iiJtA I01 tHK)-rt21)d)Ift) 'St87.71
tfl.111MI014t11=f+1"', flit 041011fI
Nft "140N , ZEI,!) 101 0,01•t 24'. ()f)f) y4.. ):t
41)irZt.}ifvt; itfl tf1)t1••I.��fi.Itll) _ ��Rtl}tl
I itii� 4211,. t°f_f("'1'1 iltle �-►`+�(�)• .1=)`l� +,)�� S:'S,K Y �+ `?
V.>ai:r{'1INV 14. "AW 101 -006,44•3 ,• �t�4 g°' i i tff
III IVI.V I1 Ai'I cA tV1;�t 11111 .r}fIII_a55_0(lit IIt3 W
Tf�I If N!`, -04 Rt 1')0N ANS') PVAN
Y 1UJ }iE SS ME,-
EIP t ? 1'3:8
S .971 fl9)
DEC 0 4 1996
)TTL PV"IIT Vz l,KS' DUE NOW
?
RECEIPT _ ....
RATE-"'
BY ��
DATE FINALED
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
ICombustion
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
VCondensate
Lines
Party Wail 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 Pibg. Test
Final
Gas Piping
PLUMBING APPR VALS
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)
ELECTRICAIYAPkOVALS
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:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
-•619-775-3500 n,•
CERTIFICATE OF COMPLIANCE
Date 11/14/96 APN # 769-142-011
No. 15017 Jurisdiction La Quinta
Owner Name Coronel Construction Per -nit #
No. 51-425 Street Calle Quito Log #
City La Quinta zip 92253 Study Area 116
Tract # Lot # Square Footage 2966
Type of Development Single Family Residence No. of Units 1
Comments
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 1.84 x 2,966 or. $ 5,457.44
i
the property listed above and that building permits and/or Certificates of OccupE-ncy for
this square footage in this proposed project may now be issued.
Fees Paid By cc/Valley Independent Bank/Samuel & Olivia Acosta _.Telephone 564-4604
Name on the check ' �^
By Dr. Carol McGrew,
Administrator in Charge
Fee collected /exempted by Pauline Pearson Payment Received $5.457.44
Check No. 129415 `
Signature
PA -A I I va, 4A A-A-6^1\—
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
7
E
JAMES D. FEIRO
=� CIVIL ENGINEER LAND SURVEYOR _
P.O. Box 12980
PALM DESERT, CALIFORNIA 92255
(6191346-8 015
FAX 16191346-2548
Dec. 13, 1996
City of La Quinta
78-495 Calle Tampico
La Quinta, Ca. 92253
Attn: Public Works
RE:_ Lot 173Desert Club -Tr. #5
APN: 769-142-011
This letter will serve to state that on this date, I field checked the finished floor
forms of Lot 173 Desert Club Tract #5 and found them to be 2.54 ft. above
the highest adjacent existing top of curb.
Sincerely,
e�d�ESS/Q�q
D.
F�g�c
�n �T O J Irmmes D. Feiro
MLS
iTl No. C-24176 E-
0� 1 19
�l CIVIL
4r46 OF.
C AL��6Q
�
)