0011-186 (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:
( 1) 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: forthis,reason
Date .:;:J!-G� Signature of Owner '` " .r. J :'..• i';�7f�: /f
L
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. h
( ) 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.
(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,provisiohs. G� J
Date: 1/ -,?e. d d Applicant s/''r;'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall,subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and.for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void,if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
I,S glnature (Owner/Agent) / "AL.W —+'1,21 V
BUILDING PERMIT PERMIT#
DATE VALUATION LOTATRACT
JOB SITE -
ADDRESS
APN [ -p II /
�,/� ` /
134 SAINIT DRI
_�
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MS ALJCI ADENUM O
78-840 S,d ITATAi7I'M
LA. Q•CJ:Qm CA 92233
USE OF PERMIT
RIMU 'sENYD1s;L T7i'�lCA?�3
ROOM*Q�jlj�
i(.�zE,gN:�RA.pr0e,3j
yMjt$`S"�iIN'�4f.1�
g2y'+ww0[7pad {q�jyyylnry'�1�'1p/ONUS[
i.Iq�l�Ylh«��1Y�CJIrIYI. W��.4$I.I�lJ1Ct,l CFVy Y.L'cLl,i,F i {Ctrl {,y';%O7A K}Li!IAM1F4�fH . w
BONUS MOON,
ESIM"n.im cogr.OF C0NSMUCHOP
PLA34 CHFr-Y FFR 101--000-139.318 MIN
f;C1t S'Y TtLfC; D tt3i�3 101-000-418-000
SUB-mAAll0-01VA7&AF-G. CIVI0.f.V ,AND 1'A.u' g0MIC.
$169.79
LIMB :f':lf¢ E-11AID FTt W.A,
0.00
TMEAL, PK1'� M-08 DUE NOW
9169,19
RECEIPT
DATE, ,, _,
BY..t ,r
DATE FINALED
INSPECTOR
1
�
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
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 ��il Ce'¢d'
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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:
DesertSands Unified School Disteict
.4.7 9504Dune 161aiik6ad"
.t+
T. t.:. .
Notice: L`a,Q'utnta,,CA 92253;;
,
Document Cannot Be Duplicated 760471'8515." `
'CERTIFICATE OF COMPLIANCE
,L
Date 11/21/00 a APNA, ` ...;604-174-000
y
No. 21237 _. <<' Jurisdiction
4 La Quinta
Owner NameAhCia Demello Y Permit #
No. 78-840 Street `Sanita Dnve : Log #
City La Quinta r } �' " . -?• zip 92253 Study'Area T
Tract # Lot # Square Footage 207
Type ofDevelopment Residential" Addition `' No.`of Units 1
Comments ddition is a tiorius room.
At the present time,.- the Desert Sands- Unified p�School Distrfc6'does not collect fees on garages/carport's; covered
patios/walkways; residential.additions under'50,0 square,feet,;detached accessotystructures or,replaceinent.niobilehomes. It
.has beewdeteimined the above-named.ownergis exempt from paying school fees,at this time due`to the following reason:
Residential�W diti 500,SO Feet or Less
n EXEMPT
This certifies that'school facility fees imposed-.pu suant to GovernmenVCode 53,080 in the amount: of
t.,
0.00 X 207. or $ `0:00 the propertylisted above and that building
permits and/or Certificates of Occupancy forrthis:square footage iri;this proposed-proje'ct may_;now be'issued _
Fees Paid By N/A - Ah)�es
cia Demello " 1phone `(
Naine'on the eheck
By Dr. Doris Wilson`.
Superintendent <`
Fee collg-ted -?exempted by Annette M±16wExempt $0.00
i C L
Check No: N/A
Signature
t ary , „ter r
.� <.
NOTICE Pursuant of Assembly Bill 3081 (CHAP 549 STATS.ilggGj_thiswill serve to.nobfy'you that the g0-0ay apptoyaI period in which you may protesYthe fees or other payment identified
above will'.begin to run from the date,ohwhictNhe building or installation permit for this projecl'is sssued`or'on which.they'a_re"paid to the'District(s) or to another public entity authorized to
collect,themon.lhe Distnct('s)(s') behalf, whichever is earlier:,,
Collector: Attach a copy -,gr countyorcityplan check application torm:,to district :copy,, for all waivers.
i'.aLA
embossed Original- Building"Dept./Applicant Copy Applicant/Receipt Copy : Accounting
/
A .
VE"WA
Plari . 2 4a
o
A-ELEVATION ONLY.
Two Car Garage
With Bonus.-Area
-:Nook Master Suite T M `
'A
M°�d aeuedcar Ba
G
_ Kitchen'
o Dressuig i
toy ytYteO CeWas �. - MWtad Cellloj ,� .
x�f
»fes �C 13 ua�«�o
Y
...%W&vdCetMS
Bath 2,
y I I' ' 'I• Ih. IlcllaltS
i I�o��i I�ItILII��IIi�III;� IldLilio Iltied,' �Vi ��...
.: IIII
`ELEVATION B & C ONLY
APPROXIMATE UVINGAREA 1262 so. rr.
Living.. £n Bedroomt3 b`, .
,au„ed<<;,,n Optional Den ° Bedroom m2,
1.
n seat
?� Inside page
r ,
r X—
SP�VI �Mashl
ni
• Ce / L__i
4, Lt� ' i dry., i
9.'�=—
n R.V. L_
i�rrrnr,?
m�uuipionui�oi'
=Access :
(some lots) t 1 O/ �/ t� 0. •V
q X� A
Optional I I
approximate Bonus Room%I Garage ;
Bedioom'.4
Living Area '° 1262 I I.
Bonus Area.+ ti
°ot3l: 9SSq: Ft. conoete wvli d dAve
concrete waft 6t dthe
a sI . _