9912-085 (AR)LICENSED CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N LU Professionals Code, and my License Is in full force and effect.
:3 M License # Lic. Class Exp.
ti p LO 61407,4 L _ 0'a 1120i
d Z t, Dlate ,1.17 '% Signature of Contracte-
O_
� F � d OWNER -BUILDER DIecuRAT ON
W Wcc
n I hereby affirm under penalty.of perjury that I am exempt from the Contractor'
~ a- License Law for the following reason:
Z( ) 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).
C {) I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O�
a Z WORKER'S COMPENSATION DECLARATION
Q I hereby affirm under penalty of perjury one of the following declarations:
;
'p (} I have and will maintain a certificate of consent. to self -insure for workers'
K W LL compensation, as provided for by Section 3700 of the Labor Code, for the
_J JQ performance of the. work for which this permit is issued.
Ai Q U (v) I have and will maintain workers' compensation insurance, as required by
j U Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
i 0 F- permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z CarrierPolicy No.
l7•. 1.1': 1. f X116
CIS
r• Q
g (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 ngt-employ any person in any manner so as to become subject to the
works,rra' compensation laws of California, and agree that,ifl sfi id become
3 Yata
'ect to the workers' compensation provisions of Section 3700 o the Labor
ee, I s II foAhwith comply with'those provisions.
>': _ Applicant
Warning: Failure to secure Workers' Comp
ensafR3n"coverage is unlawful nd
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 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 repres�ntatives of this City to enter upon
thh above-mentioned property / tlor inspection purpoos.
JSignature (Owner/Agent)'—
PERMIT#
BUILDING
.PERMIT
DATE ' VALUATION $2.1.1849 NO LOT ri.14 TRACT 289J j
JOBSI E %�-Z�,d C'-.o,°il4 VBuce (!ie�1✓��
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'.f.J C�cct�! r�':tixEj.,-t47nrr�rr
r}nA),a4trrl<1Orr
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1.,A ()U1N-I A C'A 02251
1_,A CIIJI.i�J'1A CA 92253
f7601e?f-1941 20446
USE OF PERMIT
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11.,01'1. 610. PLAN (;Hps+;tC bubH.Ist)tJ�T1) 75%) Fox
MUL PtPLA 1380 AVNCE ('W ` i#r4'J(E 3TkLJc7Ti I RE.
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LOT
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5,50
Av I'LL. .•�t{i)..A�:' 00110 $u1
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PLL.rhiBINQ.f E ilii'-(tlri)-119 tH)t} $19.25
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),7 S,S' PRIE,-PAID i t•rEES
Pi�.tiY�
•i'(lTAI, PERM.11' 1+.ERS 011j NOW
5203.53
1
RECEIPT
DATE
BY'
DATE FINALED
INSPECTOR
C2SP4k, N I I6aI
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
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
POOLS o 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:
C !/
C� v
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 banns Unu►en bcnuu►,v►str►c►
47-950 Dune Palms Road
Notice: La Quints, CA 92253
Document Cannot Be. Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 1/10/00
No. 19893
Owner NameTD Desert Development
No.
City La Quinta
Tract #
Type of Development
Street SEE BELOW
Lot#
New Residential Addition.
APN # 649-210-007
Jurisdiction La Quinta.
Permit #
Log #
Zip 92253 Study Area
Square Footage 1088
No. of Units 4
Comments CASA VIDA CIRCLE: 79-100, 272 sq. ft, addition of optional attached guest suite to house
der construction (Lot 66); and 79-111, 272 sq. ft., addition. of optional attached guest suite
o house under construction (Lot 68). MONTANA WAY: 49-452, 272 sq. ft.., addition of
optional attached guest suite to house under construction .(Lot 52); and 49-563, 272 sq. ft.,
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 atthis time due to the following reason:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies thatschool facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 1,088 or $ 2,099.84 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 CC/ Patin Desert National Bank/Judy Halpain Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Ellen Patino
Signature V
Payment. Received $2,099.84
Check No. 81519
NOTICE: pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1988) this will serve to notify you that the 90 day approval padod in which you may potea the fees ortoCrer paymeM.identified
above will boon to nm from the date ori which the building or installation.pennit for this project is assued or on,which they are, paid to itis District(s) or to another public entityauthorized to.
Wed Orem on the Districtrsxs7 beheC, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building DeptJApplicant Copy - ApplicanMeceipt Copy - Accounting
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