9905-161 (COMB)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
CN W Professionals Code, and my License is in full force and effect.
O � ch License # Lic. Class Exp. Date
r` 0 LO 463A4 f, E3 12131119:
~o Z /ate Signature of Contractor
Q
J U C:) OWNER -BUILDER DECLARATION
W WW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
U) 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).
( ) I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
0)
d< WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation,. as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q C) ( I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
ti rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
q* Z Gamer Policy No.
Cb fl}bw�4;1v i:hitll.Ai i lV�a-wJ+N9�A?t?
O
J (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 io the workers' compensation provisions of Section 3,700 of the Labor
Code I shall forthwith comply with those provisions! 'r
ate:. c Applicant._'
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 for inspection, purposes.
1,Signature (Owner/Agent) CDate_T
BUILDING
PERMIT PERMITN
9yfMib1
DATE VALUATION
�% L7•
LOT LOT TRACT
JOB SITE
ADDRESS 4i►-�'lUli ,rlt11�NI DRO
APN
��Ft�- I3c1-r�n
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ISIIDZIR DYER
ft'1'' AIAN CONS CNt1Jt`"1 ON.'
118-800 SAN 1SIDRO
P.O. BOX 1188, YORBA LINDA. 92686
LA QU1N'FA
CA 92253
CATHEDRAL CITY CA 922:34
(619)324-7929 C.M.4 3919
USE OF PERMIT
COtMBINATiON
REMODEL L & ADDITION - 369 S.F.
V ,i LUAd !1117+1
2,11, 755,00 1.e3
.i'.:)T•x1Y811.1
D MI -Y. OF C13INaT.l,iiilC.il IO
24,7105.00
11"C'M T FEE, SUMMARV
PLAN C'H..HCK.FFT.
101 -MO -439-318 Sib Aj
r"aW.q'i" Vr,Tf0'N1-TER
10 R-fo-)
ME O tANICM, FIN.'
11? I -fli30 1 1-000 0*341.50
r.Ia.t TRICAL r1E-
101-000-42,01-000 8.34.82
N't.t3�Lfl4ltVi.f k7.
101 -OW -414-000 s.' ,00
STRC'iNO NfCiT1l0W FF`F' - RFSTf)
101-f)W-24114)(10
;
c;Na�ti[ttiT<.� N�tj�
l�i•t?JU-f23,0Of1 �.f1 t�
s
Ct?F3�rt,s3'.�1, COIN' NMRIJ MON ANIS PT,AN CTIFCK
girl �►
DESS PRE -PAID FEES
YO.00
TOTAL II' E'RNiOT leF liN 011E, NOW
$561.60
�y-vu
a
RECEIPT
DATE
BYi
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &4otings
Ducts
Slab Grade
Return Air
Steel u
Combustion Air
Roof Deck
Exhaust Fans
0.K to Wrap
F.A.U.
Framing
Compressor
Insulation
_ 8 —
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 v
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
Fixtures
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
47-950 Dune Palms Road.��
Notice: La Quinta, CA 92253?
Document Cannot Be Duplicated 760-771-8515 e' ,
CERTIFICATE OF COMPLIANCE
Date 6/3/99 APN # 646-130-020
No. 18836 Jurisdiction La Quinta
Owner NamePeter Dyer Permit #
No. 48-800 Street San Isidro Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 369
Type of Development Residential Addition No. of Units
Comments
expansion
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:
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 369 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 - Mike Ruttman
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Ellen Patino
Signature (� �L��(..i,>✓C_ ''
Exempt
Check No
Telephone
t~ )� roe
17
x$0.00.,
N/A
IOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project issssued or on which they are paid to the District(s) or to another public entity authorized to
ollecl them on the District('s)(s') behalf, whichever is earlier.
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