9609-065 (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
Date �o��%"� 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.
;'riffF„ 1 C)f�F)
1171093"
(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 agreeth-at if I -should become
subject to the workers' compensation provisionsv'of Section 3700 of the Labor::
Code, I ,shall°forthwith comply with those/Vprovlsions.
Date: ="3 "17 Applicant-
\J.
pplicant 6.� X
to
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 foe inspection purposes.
Signature (Owner/AAcq%60� p f •'f Dater ' i � 'qtr.'
_.. r
PERMIT46og ms CONTROL#
;BUILDII �q PERMIT $0 409
DATE VALUATION LOT TRACT
JOB SITE ilys-v Ay lKit1V-MY VV 414 7 A Vft
APN 646J 1% 6100
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
.14)
S1 ARRS f'c1111 ffl1
s+c.1 }il/tti JJ Io
"3%YZd)5K.Ai CII()LAQUit ADR,
LA f;iHNTA rA 02 SI
(' 427I ri�A
?:l.lradl
ki 19)771,-1941. t FIE fs 2996
USE OF PERMIT
KAN 1 TF RRAZA
tiro'.€1MP, .fl, PTS ttEF1 FrTAN ART iN f't t4VC Pt A(7f; C`iii.`�IT Of, o
"21}a,'?s P.r IG31?Nl' Wlilirf)n lf!NIT i?1;VK1'; P_ h'lT
r'f )t fS?Rfi MON Z� 211,00 4F
P"03 PNT10 17000 yr
0AR NCOCARKIRT 016,00 SF
F;i`f00AT C11) (VUS"C Ole CONS1'#di?!`l40N
1i�5,5�is.;y1i
PLAtd (JI ?rCK FEW t.fl 1.-Oc}f1• � �4�-.itf1 !t7't.s�
L;ti1t1.S'f'12t,4>;''Ht3d+FLE 101-ocx -418MO $940.w
}01-1ii 0.4..71-(k)(1 S98,N)
1=FEMRICALFHPf, 1o1 -Drop -420-000 S 167"1
I'S.IMMING FIX. iel �i�4) I19 03
'.'1 ONG AAA 10N FEE' - RCS,fli 1,01-00&,241-000 $18,56
oRA1 INGFI-1'ti lila-(a)-QA•fi o S20.00
tf4 RA '11711 (1 ,1RE FrR 225-000-441-3B12 (,127.71
AWf 2 NUB LTC t'C,ACES REStJ` 7d#`OffJ-255-000 $213.95
A11' i rtrfli IC° 111,e��1 12F :ti11a 701.-00o.?`i-(3ti13-*a'j13.3
SU 3-'IMAL i..".UIvS'}Z2:LK71 01W.riND PLAN 1~"11.E+"'K
IX188 PH%-PAID(1'S
VI1.9,,
RECEIPT
DATE
BY
DA IN
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion 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
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
re/, f
I
s CITY OF LA QUINTA
or BUILDING & WTY DEPARTMENT
. 1
7012
n ECTJN REQUEST LINE
fy 7153
Owner T
AVELOPMENT LP
Contracto�SP S CONSTRUCTION
Permit Number 9609-065
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS 78-970 RANCHO LA QUINTA DR
SFD PLAN 1 LOT 64
TYPE OF INSPECTION
DATE
INSP.
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT- A/C
FIREPLACE
ROOF
BOND BEAM
O.K. TO WRAP
/
°e
GROUT Cl 4' ❑ 8'
FRAMING
INSULATION
PRE -ROOF
_
� "7 x�.
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR
EXTERIOR LATH
("
/
POOL PRE PLASTER
FENCE & GATE
SEWER,'SEPTIC TANK
FINALS
ELECTRICAL
PLUMBING
FINAL GAS TEST
HEATING - A/C
HOUSE NUMBERS ! 1
JOB COMPLETED
TEMP POWER
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
1-9h TURN ON UTILITIES OR OCCUPY BUILDING
Desert Sands.Unified School'District 1,
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 10/9/96 APN # 646-370-003
No. 14913 Jurisdiction La Quinta
Owner Name T.D. Desert Development Permit #
No. 78970 Street Rancho La Quinta Dr. Log #
City La Quinta Zip 92253 study Area 123
Tract # 27840 Lot # 64 Square Footage 2231
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 2,231 or $ 4,105.04
the property listed•above and that building permits and/or Certificates of OccupEncy 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
Fee collected /exempted by Pauline Pearson Payment Received $4.105.04
Check No. 9453
Signature (�h Lt l§AAfl �0 RLAIV,_A9n-_
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