9609-132 (AR)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 '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 �i'ssued MyiW61rkers' compensation insurance catrrier� &,policy no. are:
Carrier Policy No.
(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 provis, ons of Section 3700 of the Labor
Code, I shall forthwith comply with thoserorovisions.
Date: --a— � Applicant 4`
Warning: Faille 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
sof 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 ,r inspection purposes.
Signature (Owner/Agent) Dat
PERMIT # CONTROL #
BUILDING -PERMIT
4116
DATE y��� :VALUATION xy,3�IN,{lil LOT. -- TRACT
JOB SITE 48^� «'�AN IV.I1li1�u7
APN f1d0-1.�1 IIU
ADDRESS
-757OWNER
CONTRACTOR / DESIGNER / ENGINEER
DAVID PRICH
!ti 01M.T., WAI.DERS
,18751 SAN LAMAS K1'
51-880 H.1.RKERA
LA 04,11 NTA CA 122.5:
LA QUIN#'A CA 92253
ffitll i Ql�18 enuf luno '
USE OF PERMIT
VAf n.1 iNKN 'i2 04 »t4 00_Wt.!
120 SF ADIA'1'ION TO :MASTT.It, M_,'QR()CtM / BA1111100 I
101-141,ii' "11) COST (:iii C'ONSTRUC;TION
9,348.410
NUMNIARY
PLA'' f.341',42% iTi? 101-i)i3l)- Vi!) -318 xiti.tlS
•w'r �'.�`)'!'l L'':'t' ON FEE 101-000-418-W. $117M
&Ai01ANIf: A1.Foi 10140•42.11-0f► Si .N
11I,11Ailif s FOH, 1011-000-41409) $45.00
I:1.1_(:VRt(.*A4. TT?3"s 101-(H) )- 20.(1(113 $i9.2)
p{
:11'! - (_{! 1�IMP 1':'i: 1:`:.`�, !!)
!U M.i
LESS IIRI' MIAID VEE
$0.00
vv
1)VAI, PE14M11' I+lwWS I1'i1E l9(1W
$273.18
C
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings Al
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck /d4
Exhaust Fans
O.K to Wrap 3
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 B /
Drywall - Int. Lath /d
Final
Final
BLOCKWALL APPROVAZS
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
Neater 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
U rground Conduit
RQugh Wiring
LE Voltage.Wiring
ures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201_ 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 9/18/96
No. 14864 Jurisdiction La Quinta
Owner Name David Price
No. 48751 Street San Dimas
City La Quinta zip 92253
Tract # Lot # Square Footage
APN # 646-130-002
Type of Development Residential Addition
Comments
Permit #
Log #
Study Area 122
120
No. of Units 1
addition to master bedroom/ bathroom
Corrected Address,per City of La Quinta 10/9/96; from 48571_to.4875f-San Dim— a -s-7
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:11
{
Residential Addition. 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 0.00 X 120 or $ 0.00
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 n/a
Name on the check
By Dr. Carol McGrew
Administrator in Charge,
Fee collected /exempted by ? Pauline Pearson L ' Exempt'
Telephone
` Check No. n/a
Signature
$0.00
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
f
October 4, 1996
RIVERSIDE COUNTY ASSESSOR'S OFFICE
46-209 Oasis Street, Room 406
Indio, CA 92201
To Whom It May Concern:
Please be advised of an address change for the following residential addition. The
addition formerly addressed as 48-571 San Dimas, APN #646-130-002, the
construction for which building permit #9609-132 was issued, should be addressed as
48-751 San Dimas..
Please note this change and feel free to contact,me if I may be of further assistance.
Thank you.
Sincerely.,
BUILDING & SAFETY DEPARTMENT
Greg Butler
Counter Technician��`