0105-142 (AR)LICENSED CONTRACTOR -DECLARATION
I Kkeby affirm under penally of perjury that I am licensed under provisions of
Ch3ptek 9 (commencing with Section 7000) of Division 3 of the Business and
Pr+ ie 5lonals Code, and my LICenSE�`force and effect.
License # Lic. Class Exp. Date
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 construes the project (Sec. 7044, Business & Professionals
Code). /
() I am exempt under Section , B&P.C. for this reason
Date t �: r" •�I. 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
(a), I certify that in the performance of the work for which this permit is issued,
1461 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: f u t Applicant r ''
�W Hing: 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 thi's City to enter upon
the above-mentioned property for inspection
purposes. i
Signature--(Owner/Agent) -''� Date ! rl
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01as-142 TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER / EN (NEER
5.11-1853
LA, QUbrrA CA 92251.11
i CF",
USE OF PERMIT
67 S.F.AD1)1TION7 PE, APPROVED PL.A31S
ADDITION 617.00 9P
99MMATED CMW COM— RUCTION
M10
P.100M FPS SUMURY
71V FEE 101.0110-439.318 MOM
CONS°I~ii%'t_tC9ION € EZ 101 -WO -416-000 $63.60
ME HAMC°AL FEE, 101-000-421-000 $30.00
;<y1JWTk(CAI.IgZZ 101 QGE?-�3aC�- i)Q • .rfa
.
,"TRO'NOMiATiCYN FEE -'f MID 101.000.241.000 $,$A
W �
D
"
•
MAY -9 201
9U,B-'•1°OTPi, C:CilaKJ'RER7114j)94 #aN1 1 LAR F LA DUIN
SCE DEP
A x.45
0 . ' '- +.
$0,00
TOTAL MOW YMS DUENOW
RECEIPT
DATE
BYD
NAL
INSPECTOR ,
INSPECTION RECORD
--s
., ` "?ERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
`—•'" BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings hx
�/
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
_
(p���Q/ �Lj,��(L
F.A.U.
Compressor
Insulation
Vents
F' eplace P.L.
Grills
Fi aplace T.O.
Fans & Controls
Pt Wall Insulation
Condensate Lines
Patty Wall Firewall
Exterior Lath
Drywall- Int. Lath
Final
BLOCKWALL APPROV S
Final
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 APPROVALS
Gas Test
Electric Ficial
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:
?..0 ,, k.
Bine
1�
[�
CI }�/ty`Of .a Quin.ta
Building 8r Safety D' I h"n
r10
P.O. Box .1`504, 78-495`Calle Tampico
La.Quinta,,C-A 92253 (,61,9) 777-7012
Build hg Permit ADblicat►on" and Tracking Sheet
Permit
oO > i
Project Address: X 5'S _ m rj �j��11 V . cs
Owner,s.Name: 0,,� G
A. P.'Number. ����,' ` V b
Address:
Legal Description:
City, ST, Zip. (,
.'Telephone: —
h_one:Contractor.
Address:
Project.Description: S, R 14, L
City, ST,--Zip:A�t�t
t•i^stJ A ot>00
Telephone: hone:
N �DrG
`,= 5 �.
State Lic.`# :
City Lic. #:
ir-
Arch., Erign, Designer:
Address:
City, ST, Zip:
hone:
....
;..o.r. r
: Pe:
GnstcOccupancy:
utionTTele
State ic. #:
S L
ecf ' e ctrele one : New Add n Alter e
Pro R' air Demo
tY )
1 P P
Name of Contact Person: .•� G NSG t p� '
,Sq: Ft.:
#Stories:
#Units:
Telephone # of Contact Person:, _ �.-71 ..' `�j
Estimated Value _of Project:
APPLICANT ;D0 NUT WRITE BELOW THIS"LINE.
#
Submittal
'"'Req'd
Rec'd
TRACKING
PERMIT FEES
Plan.Sets
Plan'Check'submitted
Item -
Amount
Structural.Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24,Calcs. "
Plans picked up.
i
Construction
Grant Deed
Plans resubmitted
Mechanical
3v
School. Fees
2"" Review, ready for corrections/issue. °
`
-Electrical
6 �—
Subcontactor List
Called Contact `Per son
Plumbing
Planning Approval
Planspicked up .
S.M.I.
Pub. Wks. Appr
Plansresubmitted
Grading
H O.A. Approval
'"" Review; ready for correctionsAssue
Developer Impact Fee
Called Contact Person
A.LP.P.
Date ofpermit,issue,,'
'
-Total Permit.Fees
?..0 ,, k.
Notice:.
Document Cannot Be Duplicated
Desert Sands UnifiO School District
47-980,P-4ne !Palm $Road
La Qui.nta;,lQA,12253
760-771-.8515
�CERTIFICXT.E QFt%.COMFUANCE
Date 5/9/01 APN#- 775-241-062
No. 21.992 Jurisdicti6 n La Quinta
Own a'
Owner N me Lick ArOde
No. 557853 street Piri6hurst
city La Quinta Pp_ °92253
Tract # Lot #
Permit 0105-142
Log #
Study. Area
SquareTootage 67
Type of Development Residential Addition No. of Units
Comments
of Patio.
At the -present time, the -Desert Sarid&'- Unified Sch' oi- District; -,does :riot collei6t fees on garages/carports, covered
patios/walkWays, residential additions -under 500 squareTeet, deiadhe d'accessory structures or, replacement mobilebomes. It
has been determined'the'above-narhed.,owrier is-exempt.from paying school fees At this time due to the following reason:
Q.Q�S.q Feet or Less'
Residefifigil Add ifi*:,
EXEMPT
This certifie's that school facility fees imposed 'pursuant to' Government tode'5jO.80 - in the amount of
0.00 X 67 or. $ 6.00 the,property-'Iist6d-ab6ve and that building
permitsI and/or Certificates of Occupancy for this square _`footag in this proposedproject maynow be issued
Fees Paid By Exempt- Rick Ar6ide.
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Paula Ruiz Exempt -
Signature
Telephone, 76.0=71'-1876
Check -No.
NOTICE: Pursuant of iAssembly Bill 3081 (CHAP 549,-STATS..1998) thiswill serve to notify ycuthat the 90 -day ppproVaidentified'l:penod in Which you may protest the feesor other payment identified
above will hegin to run from the date on which the building or -installation permit for this project is sss'ued orion which they are paid to the District or to another p6blic entity authorized to
collect them on the'platrict('s)(s') behalf, whichever is earlier.
Collector: Attach a -copy of county or city plan check application form to district copy,for allmaivers.
Embossed Original- Building Dept./Applicant copy - 4pplicant/.%eceipt Copy - Accounting
13
Dear Property Owner:
An application for a building permit has been submitted in your name�'llsting yourself as the builder of the property
imp 16vemients specified.
For your protection you should be aware that as "Owner/Builder you are'the'r-esponsible party of record on such a
permit. Buildinge not required io�b signed b I, h personally performing, their
permits!ar ni e signe. y.propetty ownemun ess they
own. work..If your work is'being perfoirrie86 "ihe thd someone 6 a your".self, you ' may protect yourself from possible
liability if that person applies for the proper periniv in, his or.her name'.--'
Contractors are require : d b I y law to be licensed an&bonclie& by the, State of,,Calif6riiii1,and'to have a business.licensc
from the City or County.. They are also required by: liw"to, put, their license number orf all permits for which they
apply*.
If you plan to do your own
w . n . work -,'-.with the ,exception 6fvir'iqus,tfi8e.s that you pjam.to subcontract, you should be
aware of the foliowing information- for your beneht"ai-nd P-toteciio-n-
If you employ or otherwise e I rigage anypersons other than a your - ur im . mediate. family, and the work (including materials
and, other costs)Js $2,00*.dd I or more for 'thele'nh t1re project; andsuch`p"erions are not licensed as contractors or
Su6co'n'tractors,.then you may be an employer.
If you are an employer, you must register with the Siate irid'Federal Gov6rnment.as an, employer'and you are subject
to several obligations including. State- and FeclerAil, JnC`6me,,tax- withholding, -federal ..social, security taxes, worker's
compensation ins-uranci,,dis'a'bility insurance cosis is and:unenqlovrriehrt6m-p�e irsation contributions.
There may be.financialriigksfor y6y. if you do not earry
carry out th�es`c obligations, and these risks are especially serious with
respect to worker's compensation in . surarke.
For rr . ibre specific information :about your obligations un deriFedera`11aw; contact the Internal Revenue Service (and, if
you wish, the U.S. Small Busine��l-Adminitiatioii')..-For ,ifi,6're specific tnformation about your obligations under State
Law, contact the Department of'Beriefit Payments.and the -Division of{Inustrial Accidc'nts.
If the structure is intefided'for sale, property owners
rs who are not licensed.- contractors are allowed to perform their
work personally or through theirown employecs,.'wAoPt a` licensed',ccintria6i or'sAcontractor, only under limited
conditions.
A frequent practice of unlicensed.persoris professinigtobe contractors. is to s ' ecuie, in 0 wner/.Builder" building
permit, erroneously implying -that the,property o . wne.r . is pr(.)Viding,his or.he'r own' labor and material personally.
Bdilding permits are not required to be,signed by' property 'o . wri&s -unless they are performing their own work
personally..
o6tain4b�;contaciifig the' 6ntra" t6ts' 'State License Board in Your
Information about licensed contractors may b;,, C
community Street, Sacramento ,-C,ali.'f6inia'05814-
Please complete and return the enclosed owner -builder ve'rificAtion form so that we can confirm that you are aware. of
these matters. Thebuilding permit will not be'issued'untiFthe verification is returned.
Very truly yours,
CITY OF LA QUINTA .
DEPT.- OF -BUILDING AND. SAFETY
78-495 Calle Tampico
La Ouiaar-eA-92253 'I
777-7012
(760) 777-7, 1,
�4�ER'S'§l G__'N4AftYR—E DATE
PROPERTY ADDRESS'
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PAINTING [
CITY OF -LA QUINTA SUB -COQ CTO -ft UST ML ��ichi.
Atm BUYER
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PERMIT NUMBER OVifNER ��`��
Onfy persons.appeering on this fist or their employees , authorized to work
r/
�.Eknldrm
be' approved
by the.Bulding Dil.vision prior to commencement of work: Failure to comply will result in a stoppage of work ar►dlor the. voidance
' d
on'this.job: Any:changes to=this fist must
'For each "a licable;trade, allAnforfnation re uested below must be corn feted by ap licant. .-On File' isnot an acceptable hes nse.
r
m
FiN�
of bui ding.permit.,,
!root I Classificatlom •: Contractor..;
„>. stele Corruataot's t tlYoilcers ti�rtae
w License Nurnt, E!P- Date
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CornpanY t�enls
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Cfe ..sem? license Number: + E ip. Dots Csrbi 1Meiee PAY
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PO
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 ❑
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONRY ❑ FIREPROOFING
JOB LOCATITN" TSI J,� .SVLA
;� 'I
REPORT SEQUENCE N0.
TVP - F�IjCTURE I� G,1�
PERMIT NOQ
DC14/f
S$
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHIT T^
IN CTO
HRS, CHARGED
'
ENGINEER G
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL / _ SUB
DATE CONTRACTOR L.(Jti CONTRACTOR
e;t-&T--7TA ,S4, A g
r
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE, O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
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.
\)n \.7--"
17 GNATURE OF REGISTERE14 INSPEC R
Wo ta%
DATE 6F REPORT REGISTER NUMBFFt