9803-050 (BLDG)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
488234'- B 12/31/97
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&RC. 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:
Cartier Policy No.
STATE FUND 626355-97
(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 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..
BUILDING PERMIT
DATE _' / _ VALUATION $1,846,20 LOT
F lx
PERMIT # C,9NTROL #
9803-050
15 TRACT PS4 2
ADDRESS 43-681 PALERMO COURT "P" 609-080-013 '
OWNER - CONTRACTOR/ DESIGNER/ ENGINEER
THE EXCHANGE GROUP ROGER SNELLENBERGER 8c ASSOC.
PO BOX 13335 78615 NAPLES DRIVE, LA QUINTA 92253
PALM DESERT CA 92255 PALM DESERT CA 92255
(760)772-0222 CBL# 1858
USE OF PERMIT
BUILDING
SUPPLEMENTAL TO PERMIT #9712-053, ADDING 34 S.F. OF LIVING
AREA TO EXISTING SFD UNDER CONSTRUCTION (CONVERTS LOT 15,
PLAN 6BR TO 6BR REVISED).
TRACT CONSTRUCTION 34.00 SF
ESTIMATED COST OF CONSTRUCTION
1,846.20
PERMIT FEE SUMMARY,
PLAN CHECK FEE
101-000-439-318
$35.00
CONSTRUCTION FEE
101-000-418-000
543.00
ELECTRICAL FEE
101-000-420-000
S.67
STRONG MOTION FEE - RESID
101-000-241-000
$.50
INFRASTRUCTURE FEE
225-000-443-342
541.54
ART IN PUBLIC PLACES = RESIC 701-000-255-000
$4.62
SUB -TOTAL CONSTRUCTION AND PLAN CHECK I$125.33
LESS PRE -PAID FEES $0.00
TOTAL PERMIT FEES DUE NOW 1 $125.33
RECEIPT DATE BY DATE FINALED JINISPECTOR
Signature (Owner/Agent) Date
Notice:
Document Cannot Be -Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE ,OF .COMPLIANCE
Date` 3/11/98 APN # 609-080-013
No. 16714 Jurisdiction La Quinla
Owner NameThe Exchange Group Fermit #
No. 43-681 Street Palermo Court Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 34
Type of Development Residential Addition `
Comments -
Additional square footage added to Certi icate q. Ft. '
No. of Units 1
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 re-ilacement 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 La the amount of,",,
1.93 X 34 or $ 65.62 the property listed above and that building,3�i J f, ,c 11
41
permits and/or Certificates of Occupancy for this square footage in this proposed project may row be issued
Fees Paid By Cash/Anna Lozano Telephone 77.2-0222
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Rosita Jones Payment Received $65.62
Check No. N/A
Signature
NOTICE: 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 prctesl the fees or other payment identified ,
above will begin to run from the dale on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
NOTICE:
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
%:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -Q
Underground Ducts
Forms & Footings -
Ducts
Slab Grade / yf ,
Return Air
Steel
Combustion Air
Roof Deck ,
Exhaust Fans
O.K. to Wrap - 3 c
Framingl� —Q
F.A.U.
Compressor
_
Insulation �5f -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath _
Drywall - Int. Lath
Abo F7lZ
c'0Z O -007
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 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 J'_ 3
Appliances
Final
Final
Utility Notice (Gas)—((=Q
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
ExteriorReceptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
r
Final o
Utility Notice (Perm) ��/!
COMMENTS: