0307-322 (AR)LICENSED CONTRACTOR DECLARATION
),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, 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 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 provisions.
Date: 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 v
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancell
I certify that I have read this application and state that the above informati
correct. I agree to comply with all City, and State laws relating to the bui
construction, and hereby authorize representatives of this City to enter o
the above -mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
cc;�. x ! RLVL1,,
OWNER
CONTRACTOR / DESIGNER / EN INEER
JOiNS) d
.l..A. tray F. ? 7.iV'S i� �'a .. � i.;..�1 «7
USE OF PERMIT
y+ ` t` 4
2113 !;.'r. A'�OO&? At-0 4� A 1.0H ;I.fA:rAi'� '5131 C13C.
TRACT
Jr..531il.A7 CO-Sr,"CO-Sr,"M CO
EIAC rIZIC'AL Pr?,i "tit 4"-420-(a00
'ITRONG Mt)";"IUP M::' - i{MI) I01 000-�41-000 I :t
r")flt"�,.". ��Al'hl..i'\tt•�.i�l w"1�f.;i4.6A (..l_L�.`''1 > i.�'.t,'t .4iCYY��H�.
016;003
BY D F LEf��
SPECTOR
- (/
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
_
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 rest
Electric Final
Waste Lines
Heater Final
Water Piping
4.1
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)
ELECTRICZ 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:
CERTIFICATESOF COMPLIANCE 110. c�
Desert Sand§ Unified School=:District z4�°o
47950'Duhe. Palms Road;..
Q BERMUDA DUNES
Date 9/12/03 La Qu i r ta, CAy 91253.".C/) RANCHO MIRAGE 0
INDIANWELLS 'ter
No. 24951 (76,0)' 771 =85115 �� P LA gUINTAT
cid INDIO i
Owner- Brad Johnson APN # '604-163-006
Address Jurisdiction La'Quinta
City La Quinta Zip 92253 Permit
.=r
Tract # Study Area
Type Residential Addition No: of Units 1
Lot # No. Street S.F. Lot # No.. Street
Unit .1 78810 Sanita Drive 273 Unit 6
Unit 2 Unit 7
Unit 3 Unit.8
Unit 4 Unit 9
Unit 5 Unit 1.0
Comments
S.F.
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patibs/walkways, residential additions under
500 square feet, detached accessory structures (spaces;that do not contain facilities fo(living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. 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 50.0 Sq, Feet or Less
EXEMPT
This certifies that school facility: fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et S64 -
in the amount of $0.00 X 273 S.F. or $0.00 have been paid for the property- listed above andahat
building permits avid/or Certificates of Occupancy for this square -footage in this proposed project may now be issued.
Fees Paid By Exempt - Brad Johnson Check No.
Name on the check Telephoner -
Funding, Exempt
By Dr. Doris Wilson
Superintendent
Fee collecte
Signature
Payment Recd
$0.00
Over/Under
f
\ /
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notifyyou'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 permitforthis project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them -on the Disirict('sj behalf' whichever is earlier.
NOTICE: -This Document NOT VALID, if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy -'Accounting