9604-061 (SFD)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
tvDate r'.!%� Signature of ContractorU 'I"
i
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.
11) 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 F'(WO Policy No. 6205595
(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 3100 of the Labor
Code, I shall forthwith comply with these provisions.
Date: � 11 1i 1, `' Applicant 1 l �. t . �•
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 Io
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& 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.
Signature (Owner/Agent) t '" �� Date `t I 'w 7`4=
/
BUILDING PERMIT PERMIT# CONTROL#
%044061314 5
DATE 41171% VALUATION $1 Z'3,6V4..111 LOT §w TRACT 013141 S '
ADDRESS 44-570 I�.A.i_ A CIRCLE � JOB SITE
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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55695 FEiIBLE
LA QUINTA, CA 9225'-+
[,.11 QUN` A CA 92254
i(,1OY777-7766
(6M)7*77.7 66 C",F3U 1858
(",idAR] 1.5 P i 3rt3'u.rQiJ1�
USE OF PERMIT
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WST1ic1 X .D COST OF t`17RS'TRi3C WN
121.684.10
PERMIT '1 EE,St' RiMAfi'.1C
PLAtd'CHE'Cl Fr; 1Cd)4100-439-3199
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hy1`OAf4"I MO` ION i1:T.t� - M-3,SYD 101-M-2111 t - $12.17
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ORAUINcl-EE 1171-000-423- )0 $20.(16
INFRM"Irt7UCI URE FE13 ' 25-(KI0 X13 -3,1x? $2,7:37.89
AIRfN Ptf01,1P', PLAC.TS . R ,fpr 701-0WQ 15540)
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.14. 176M
LESS PRE -PAID pFrC s
50,00
RECEIPT
DATE.BY
DATE FINALED
IN
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel 0
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap p
F.A.U.
Framing logCompressor
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 APPR VALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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 44Pool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 0(4
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final :710 M12 4
Utility Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111 `
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE ,
Date 4/17/96 APN # 604-262-019
No. 14337 - Jurisdiction La Quinta
N. ' Roger Snellenberger & Associates, Inc.
Owner Name'Permit #. -
No. 44570 Street Pala Cir. Log #
City .La Quinta zip 92253 Study Area 228 5
`Tract # 23913 Lot # Square Footage 2015
x'
.Type of Development Single Family Residence 'No. of Units 1
Comments
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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed}pursuant to Government Code.53080
in the amount of 1.72 x 2,015 or $3,465.80
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_.
W
Fees Paid By Roger Snellenberger & Associates, Inc. ' ,. Tele0one;n,777 7766
` Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received. $0.00.
a Check No. 11830
PSignature ,i x x Q a.,^_o `� 4.,1A A & LrV�-
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
i
• R
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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed}pursuant to Government Code.53080
in the amount of 1.72 x 2,015 or $3,465.80
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_.
W
Fees Paid By Roger Snellenberger & Associates, Inc. ' ,. Tele0one;n,777 7766
` Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received. $0.00.
a Check No. 11830
PSignature ,i x x Q a.,^_o `� 4.,1A A & LrV�-
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