0003-141 (AR)co
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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
538171 B 08/31/201
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.
STATE FUND 22921938
(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 3100 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
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 Quanta, 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/Agent)
Date
BUILDING PERMIT PERM10003-141
DATE VALUATION 88,335.30 LOT TRACT
JOB SITE
ADDRESS 48-165 PASEO TIEMPO LANE
AP"
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CHARLES D & NANCY H GILBERT
RICKLYN CONSTRUCTION
48185 PASO TIEMPO LN
30640 VIA.LAS PALMAS
INDIO CA 92201
THOUSAND PALMS CA 92276
(760)343-5500 CBL#
USE OF PERMIT
RESIDENTIAL ADDITION
107 SY ROOM ADDITION TO EXISTING RESIDENCE ONLY PER
APPROVED PLANS
CUSTOM CONSTRUCTION 107.00 SF
ESTIMATED COST OF CONSTRUCTION
8,335.30
PERMIT FEE SUMMARY
PLAN CHECK FEE i 101-000-439-318 S70.20
CONSTRUCTION FEE 101-000-418-000 5108.00
MECHANICAL FEE 101-000421-000 $21.50
ELECTRICAL FEE 101-000-420-000 $18.75
STRONG MOTION FEE - RESID 101-000-241-000 S.83
GRADING FEE 101-000-423-000 $20.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$239.28
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$239.28
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
qf`^ �` 4 LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C1,, ter 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
;391 7 i B WWW i J 20(
Date i (' rJ1.';0J`0
Signature of Contractor /ll'�-�j 1 �f lz
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:
- O 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.
(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.
(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
Code, I shall forthwith comply with those,provisions.
Date: "'ij L+-.`LG"Applicant I �".t�. .r_•A(
P
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, indemnity
& 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/Agent) �' ra° Date
PERMIT #
BUILDING PERMIT
1Nf=).i-F1
DAT/ /\. j VALUATION ��• � fir\ �i� LOT _ TRACT
JOB SITE ADDRESS413-'♦ 65 Pt11SLO ��Ad1,1�5tM LANI !!,
APN -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
(''f f A'f) T 'rrr. rZ C4 ht A hT/''v t'f "'TrY \:'Ci fA"!'
✓f ad ::S,�.n..a+4f �-11y 1{7_,,i •-,, It I. ♦Dl 1.Jr.fla lt.E
r, rf `i( 1 'VTT '�r,7eiC'I'f> f T/-1' I -MT
f.i.u/t'n
4619_5 ;.ASO T/F1ViF0 LIN!
!661410 VIA I )k,;', !ALN WS
iNj_, ilk:) CA 9270.1
THOUSAND PALMS' C 1ryU92276
i
f%�t�ii4,1rS
CRT
fi
USE OF PERMIT
itESID,RNU'1AL D)DMIO
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I.ti � �.� ��/�-.�� �u,1-►�'�It'sEv � u ,�T.r� €tl:f�.Ii�I�tJCi�, uN'�. � :�� .
APPROVED 11,ANS "
:4.
Ai.V01111:rtlV111.1111 CO3"I oil CON tii� •Y k�r��
!iw Y.7.,AUb
'PLAN CHECK d a, 101-000-439-3113 $70.7.0
r o"Nc, rR1 RCTION Ft. P, 101 -Ong -41 R -Mil 0 $10A tui
AMEt..all°ilNI(111i.1'M nl.1.11010 If21t-00^ u12%.5fj
�.
L'.t.4:c.•!R1CAL[!1', iCJ1^GUG•$2U-GOii $18.75
3
S`372v.Nc fa2OVON FEE - RJES) 101-000-241-000 .z3A
nf: ADfN(; RL s7 101-000423-000 s20 ftti
:.j
: • . .
W
SIT, T 4. f'(yfAi,(IONIST_ R(.1C;rioN ANI1 PI.,AN r`.Y-It?C;X;
$24949
RECEIPT
DATE
6'1^.
DATE FINALED
INSPECTOR
J''�'J
d
INSPECTION RECORD
4 OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
'7
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
O.K to Wrap
— Ccs
_ ptJ
Exhaust Fans
F.A.U.
Framing
4,—
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
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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:
Notice:
- Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Pahns.Road
`LaQuinta, CA 92253 i .«
760-771-8515
CERTIFICATE OF COMPLIANCE '
Date' 3/15/00
No. 20161 Jurisdiction
Owner NameCharles D & Nancy H Gilbert
No. 48-165 Street ' Paseo Tiempo Lane
City La Quinta zip 92253
Tract # Lot # Square Foot
Type of Development Residential Addition
Comments
107 sq. ft. Room Addition.
APN # Not Available
La Quinta
Permit # 0003-141 r
t
Lo; #
Study Awa
age 107 r
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 0ollowing 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 107 _ or $ 0.00. the property listed above and that bolding
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid B N/A Ga 1 Pa
Y - Y Y Page
Telephoner 760-343-5500
Name on the check
by Dr. Doris Wilson,f.
Superintendent
Fee collected/exempted by Mary Ann L. Borja Exempt '`t;�(p�'f-/, $0.00 y
Check No.
Signature OM
NOTICE: Pursuant of Assembly ill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may prote6t the fees or other payment identified
above will begin to run from the date on which the building or Installation permit for this project is sssued or on which they are paid to the District(s),or toanother 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
66
all
DecembeT 20, 1999
' and 4�Us, �C harles Gilbert
r�
C48-'165 Paso 1'ietizp�, T„ane �:
I.s l�uii�ta,
CA, 92253
1 ;dear Mr. and Mss. Gilbert.
t iz3).�itc1l G1 --
-:a a ,
'i'lle Ranrhu� 1 a t�u�r!t�r�hztec#t�ra1 ��s�mmittee'has rc�2� ,,�� n�� , r
' revised x�iii cue' �plai)s tib et to c�ir111r nts,' The revised plans Nve-c rec-el.v' d ii () ' iaTili C fJn . .
No eti ber -1�
1. l 99
-
1``e will need the S2 iU.U�� coils,tu&kIn deposit prior to (Inc erase: Of::;�t�
' v6u-but not ,;. yoAjr �;��ntrac+vl. Please
n <,:i�ae +tem„fined b
'The construction t�ila2 i _n
12ZV� 11Im t;OIne 2C► t}te , +`35�?L i CiLla office to .`ign t})l `<�{?11}.3tiUW' � r!i32 :X�' the C)Z1sCC Of.
,.
Both itenis will need to b>
CplzTpltt d rtoiv 3`ha;in `':)li tCir �%):xr iiiL';i�'�` i;1 Uig` the
r
plans. �I hope you have a very fVICITV' Christillas,
� d utierrz� Prtrp i~. ,ate er
er,S i�.iic�,) Tor n.&ncho La Qu:rtn
jAtv
PO
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Prole sii�:nal Communit} �Iaiiag n{"�
el n d ent
y r Post O "r RFs. Dt'
7 p office,,Box 47.2
Palrri':Desert; Cd? ) F
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