04-5461 (AR)BUILDING & SAFETY DEPARTMENT
G, sy5 1WYtQ.,rf3�f.L.- i. (760).7 77-7012
OF 9. -495 CALLE TAMPJCoFAX (760) 777-_7011
LA Q.uINTA,, CAL[FORNIA 922;53 INSPECTION" REQUESTS (760) 777-7153
BUILDENG PERMIT
Application Number . . 04"'0-000-5461 Date 10/0.9/04,
Property Address 55.573 PfiN-EHURST
APN : %7 7.5' 2 41 '0 5 6 -
Application description :' ADDITION .;RESIDENTIAL
Property Zoning` ,LOW.- DENSITY RE-S:IDENTIA_ L
Application,:valuation° .8647
owner :w Contractor
-- - - -- -- - -- _ _ _ �_
RUNYARD MICHAEL °. CBR ENG CONTRACTOR
55573 PI•NEHURST 54,015_ SOUTHERN HILLS
LAQUINTA CA .92253,,. LA:QUINTA-� j CA 92253'
(760) '.,771-2278
WCC':... STATE FUND
".-WC: 15.42568 08/01/05
'CSLB': 5:04183 0:1/31/05
,GCC: A' B<..,
------ Structure Information ADDITION.@ SE,COND.BDRM &CART GARAGE -----
Construction Type.. : TYPE V- NON -RATED
Occupancy Type DWELLG/LODG.I-NG/LONG <=10
Other struct"info . . CODE EDITION 2001
-GARAGE'SQ.FTG: 151.00
FIRST FLOOR; SQ FTG,. 73.00
Permit BUILDING PERMIVT'�
Additional'desc`
Permit Fee 108 00" • Plan' Check -Fee 70.20
Issue" Date" Valuation 8647
,. .
Qty Unit Charge Per L,' Extension`
BASE FEE: 45.00
7. 0 0.. • 9.. 0.0.0,0' THOU BLDG 2, 0:01.7`2,5 , 0 0!0 63.00
------- -- 77 --
Permit . . ELECT— ADD/ALT/REM
Additional desc
.Permit -Fee 20.58 Plan- Check' Fee 5.15
.Issue Date :-.Valuation 0
Qty Unit Charge Per Extension
BASE' FEE 15:00
ti..,:
73.00 03.50 ELEC. NEW RES 1 OR 2 FAMILY 2.56
151:00• 0200 ELEC:GARAGE OR NON-RESIDENTIAL 3.02
x.
--------------------------------.--------------------------------------------
Special Notes. and Comments.
Addition `-' Sewn&,, Bedroom (73 sgft) and
a�
P.O. Box 1504
f�
78-495 CALLS TAMPICO VOICE (760) 777-7012FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 0 J 'q't� � Date:—o
Applicant: I Architect or Engineer:
Applicant's Mailing Address:
Architect or Engineer's Address:
Lic. No..
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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 ClassLicense No.
Date
'' -t Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a per subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 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 fbr sale (Sec. 7044,
Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' 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
ued.wlywoticers' compensation insurance carrier ap goljcy number are:
Carrier hr;.. Policy Number /S Sr23-Z, a
_ 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 /-06/ ( ,o
f —%5 Applicant C.� 3)"
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Ouinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 a to rfiply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to a upon the a v -men ' prope for inspection purposes.
Date Signature (Applicant or Agent):
Page 2
Application -Number . . . . . . 04-00005461 Date 10/09/04
---------------------- I -----------=------------•------------------------------
Special Notes and Comments
Golf Cart Garage (151 sqft)
----------------------------------------------------------------------------
Other Fees . . . . . . . . . ART IN PUBLIC PLACES -RES .00.
ENERGY REVIEW FEE 7.02
STRONG MOTION (SMI) - RES ,86
Fee summary
-----------------
Permit Fee Total
Plan Check Total
Other Fee Total
Grand Total
Charged Paid
128.58
.00
75.35
.00
7.88 .
.00
211.81'
.00
Credited Due
.00
128.58
.00
75.35
.00
7.88
.00
211.81
•f ` l
CERTIFICATE OF COMPLIANCE ��,1Fisc
Desert Sands Unified S'chool:District
• 47950=Dune, Palms Road Q gERMUOA DUNES �
Date 10/12/04 La, .Quinta,,CA 92253 rA RANCHO MIRAGE
INDIAN, WELLS
No. 26508 (760).,-771-45.15 d�.P LAQUINTA �y
QINDIO.
O
Owner APN # 775-241-056
Address Jurisdiction La Quinta
City Zip Permit #
Tract # Study -Area,
Type No.:of. Units 1
Lot # No. Street S.F. Lot#: No. Street S.F.
Unit 1 55573 Pinehurst 73 Unit 6
Unit 2 Unit 7
Unit 3 . w Unit 8 -
Unit 4 Unit 9
Unit 5 Unit 10
Comments Bedroom Addition
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 (spaces that do not contain faculties'for hying, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt f m 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
Education Code Section 17620 and Government Code 65995'Et Seq.
in the amount of . $0.00 X 73 S.F. .or $0.00. have been paid.for 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 Exempt - David Roberdes Check No.
Name on the check Telephone 771-2278
Funding Residential
By Dr. Doris Wilson
Superintendent .
Fee collect4
Signature
PaymentRecd
NOTICE: Pursuant to Government
other payment,identfiedabove:will
those amounts�are paid to the Dist
$0.00
Over/Under
Section 66020(d)(1), this will serve to notify you -that the 9"ay approval period in which you may protest the fees or
i to';run from' the date on which the building or installation permit fog this project is issued,'or from the date on which
,or to another public entity authorizedao colledthen on the District('s)',behalf, whichever is earlier.
NOTICE: This Document.NOT.VALID if.Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
TANDY'S
INSPECTION INC.
PO BOX 13766
PALM DESERT, CA 92255
SPECIAL INSPECTION DAILY REPORT OFFICE/FAX 909.769.9717
PAGER 760.776.3339
TYPE OF INSPECTION PERFORMED
SAMPLE INFORMATION
,'
SUPPLIER
TICKET NUMBER MIX NUMBERI TIME
AIR TEMP:•..
SAMPLED
DATE
P�
o -9.-(o -Qy
PHYSICAL ADDRESS
_
PERMIT UMBER
\
JOB NAME
'
OF STRUCTURE
M rL IA
ARCHITECT
ENGINEER
GENERAL CONTRACTOR
SUB CONTRACTOR
G
_
DESCRIPTION -OF WORK INSPECTED--- --
S a2\) V \PDX. O r q :Dow --- S I"Im S`3. VCA ct/1 t i "OuEs
Vek- 11
I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK,
UNLESS OTHERWISE NOTED. AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLMABLE
BUILDING LAWS.
CC:
PECttTORS SIGNATURE
INSPECTORS CERTIFICATION AGENCY AND NUMBER
SAMPLE INFORMATION
,'
SUPPLIER
TICKET NUMBER MIX NUMBERI TIME
AIR TEMP:•..
SAMPLED
SAMPLE SLUMP
TEMP
TIME IN MIXER
LOCATION
WELDING INFORMATION
PROCESS
WELDERS NAME
CERTIFYING AGENCY AND CERTIFICATION NUMBER
I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK,
UNLESS OTHERWISE NOTED. AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLMABLE
BUILDING LAWS.
CC:
PECttTORS SIGNATURE
INSPECTORS CERTIFICATION AGENCY AND NUMBER