0310-217 (RER)`"
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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
521353 'ti MC � 111.30/2(
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 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 STATE FUND Policy No. 040 04701
(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 the Labor
Code, I shall forthwith comply with those provisions./
Date: "a -Applicant—
Warning: Failure to secure Workers'�Compensatlon coverage is unlawful and
shall subject an employer to criminal pen.Ities 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 fofr, insppectionnpurposes.
Signature (Owner/Agent) Date �• 3
BUILDING PERMIT PERMIT#
0:910-31.7
DATE �� i� �} VALUATION SMIM-00 LOT TRACT
JOB SITE
ADDRESS 49-M CEDRO! CIRCUO O
APN
OWNER ,F:
CONTRACTOR / DESIGNER / ENGINEER
TP.R. Y MHC H
G. L•. SCRIVEM CCtNSi2`CTMON
49-020 CEDR.OS CIRCI E
61400 MCCA ROAD 4260
LA QLTINT.A. CA 922S3
MOUN'TA19 CRNA ” Cad 92561
(760)349-332- CI31.4 2484
USE OF PERMIT
R"11)MM YOWOu .
i' PPLAC:}T OOR3fb1f1N1)0WSf1NTEa10R Ki'i}iI00EL OF 14ON,,STRUCTi3PAL
SOFFITS &,ARCIiE2 W)TI3 ADDITIONAL ELECTRICAL & PI.i3Iv1811 O PFR
PLANS.2001 C UC.`..
CONTRACT AMOUNT 10,000.00 IS
ESTMA'1`M C'00.'0,F CO;lV' U(M- OW
101000DO
1"%R.?VUT Y". SITM11I AIZY
ELECTRICAL FFI"S ) 01-000.420.000 827.G0
PLUMBING FEE 101-060-41.9-000 $33.50
PLAN CHICK FFM 101.000-439.318 V61
CONSTRUCTION Ply .10.1-00"18-000 $117.00
STRONG MOT iON FEE - ARSID 101400 -
400 -OCT
OCT 27 2003
CITY OF LA 61UINTA
FINANCE DEPT.
SUB -'3 fAC. COAT UCY10H .AM) PLAN CWD.°T,"
$253.55
LFM PMPA6FM
$0.00
T[t�e�p� �y •ply ��yq �y�y C p�ap�� �T/y�p(.
Fb'.lAL Pilsl!�.�{-16..1.ETI.�el` SJ✓C-J:. J,�O9V
�a�{� � g
X9253 W)
RECEIPT
DATE -
BYr
DATE FINALED
INSPECT
v; .%7 v
-#
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
--1
Compressor
Insulation
— 3—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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
OX 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
Fb(tures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Date
8/30/05
No.
27602
Owner
Frank & Judy Keener
Address
49-020 Cedros Cir
City
La Quinta Zip 92253
Tract #
Type
Residential Addition
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
-La Quinta, CA 92253
(760) 771-8515
APN #
Jurisdiction
Permit #
Study Area
No. of Units
4�'3�lFLEDslot
zo
BERMUDA DUNES
Ln RANCHO MIRAGE d
r INDIAN WELLS ti
PALM DESERT y
LA QUINTA
U!�,QINDIO y�
O
646-210-014
La Quinta
1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 49020 Cedros Cir 156 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, residential additions under 5
00 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile ho
mes. it has been determined that the above-named owner is exempt from 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 156 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 - Mike Apostolou Check.No.
Name on the check Telephone
111 m ing Exempt
By Dr. Doris Wilson
Superintendent�L.
Fee collected /exempt y har MCGilvrey Payment Recd
N fiver/Und6r
Signature c
NOTICE: Pursuant to Government Code Section 66=(d)(1), ttWwill serve to notify you that the 90 -day approval period in which you may protest the fees o
r other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the Districts) or to another public entity authorized to collect them on the DistrictCs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original -Building Department/Applicant Copy -Applicant/Receipt Copy - Accounting