9609-109 (AR)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.
ce:#- Lic. Class Exp. Date „•
Date';/Signature f 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:
( ) 1, 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. 13u5ines9 8 Prnfessinnals Cnria)
( ) 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 formorkers'
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 37001QfLthB„Labor Code, for the performance of the)W.or�Kufor which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver Policy No.
(This section need not be completed if the permit valuation is for $100.00 or. less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions -of -Section 3700 of'ttfie Labor
Code, Is,hall forthwith comply with (hose groyisions.
Date: 111'71$- C/ 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 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 inspectionpurpo es.
Signature (Owner/4,0- Ott), Date
BUILDING. PERMIT PERMITS#�}*I{♦s) CONTROL# '
DATE VALUATION LOT. TRACT 4045
JOB SITE &'t!I<+MY t W01Vkrul APN VY{► J9➢l►-UY➢J
ADDRESS
I CONTRACTOR/DESIGNER/ENGINEER -
SPARKS CON.I.KIRUCTRIN
48I6PASO iiENIPO LN 79295 RANLi tG Ltl QU1N 1-A DfL
LA QUIN!'A. CA 927$3 LA QI J1lv'r.A CA 922.51
(C,19)771-1941 CAL# 1996
USE OF PERMIT
RIII W13tl '1 AI..1►bV)I'lik)H
74-0?0 Ai-! SSANl;)OCi, STK
PAIAI 5ls'4.FN t', r,A WYA 619.779-5
1<•:S't•lMA.•i"ED COST OP (;OJtiS'.i'.IMC710N
PERMIT F.EC tit'tC111NA141
P1. AN r,fVCK'['FC: $64
"< INSITUXT1ON .FEE .101-000-418-000
i l�Ck 11t1CA{, h%q� 101-000,420.000
.5
.00
.72.
SLrl3=1MAL LOWMUC;TION.AND € LAN C REC K
LESS RE -PA l) :FE S
RECEIPT I DATE
Tt)T'A1, Q'.ERMIT" FERS 1)F9 NOW
7,233.20
DATE FINALED I INSPECTOR
5104.07
$0.00
$164.07
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 Yo
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath 16, 79
Final
Final -
POOLS - SPAS
BLOCKWALL APPROVALS
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
COMMENTS:
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)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 9/17/96
No. 14861 Jurisdiction
Owner Name Mr. & Mrs. Gilbert
No. 48165 Street Paso Tiempo
City La Quinta zip 92253
Tract #
Lot #
Type of Development New Residential Addition
Comments
-nc ose covered patio.
APN # 646-360-003
La Quinta
Permit #
Log #
Study Area 123
Square Footage 112
Pio. 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:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code !,3080
in the amount of 1.84 x 112 or $ 206.08
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=1941
Name on the check-'
By Dr. Carol McGrew
Administrator in Charge
y
Fee collected /exempted by Pauline Pearson Payment Received $200.08
Check No. 1207
Signature
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