9803-126 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affir rg under penalty of perjury that I am licensed under provisions of
Chao} gr 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
17/31/47
/Date `"' Signature of Contractor-
OWNER-BUILDER
ontractor 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).
( ) 1, 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.
STATE 62635547
(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.
dDate: ILl F tY 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.
VSignature (Owner/Agent)r- e, /��" Date"` -
BUILDINGPERMIT PERMIT; CONTROL#
DATE ; VALUATION LOT' � TRACT
JOB SITE/ `
APN
ADDRESS 4:+652 PLAI..1~.�RN11.0 Cii3l�t`1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
THE WXC'<HANGE C'M(` OP
1.C)ia1:1? 1�1E?,I.,�.i'.�s'F3� dal i�. c1f•.c°( 4ti C'..
NC:� t30;: IM35
T6615NAPLES S�aUVE, LA QUIN'[ �i 9`22`3
T'A.1.,M DESl X.t' CA rz255
Ptif.:I41 DtS.k V CA 97155
(76q)772-0222 VBL4 11M
USE OF PERMIT
61AL.1)tNG
SUPPLEMENTAL TUC%fCkill #9711-115, ADDING N S' i . JR i-iVli• O
ARE'A.T06X1Sf1f4iSH)M.9 RCONS'1°t'UC'l'1CN;C.ONVE+;l`;3.LOT9,
PLA1116AR'fTO6AR 1tJ,_*,V131:1i)
`t`i°AC.1. C.'OMTRUCTi014 34.(M Sr
MAR
R 2 0 1998
CITY OF
LA QUiNTA,
T.'INIAn} 0 :`Q83 -0 CC1iZT.�'ii
PR*RM1 FCESOM149Ai1Y
1'J, AN C ili(.'IK. PPE 101-0()0-439-318 $:1�o0at
fX)N5TRTX"1'10.14 #'mss 101-1700-419.OMI
ELECTRICAL FEE101 000=�f',D-Dia $.67
STIto NO NIOTTON .FII - RIJS1f3 .101-000-241-000 &50
iNFRA,817RL1'C.1'Uft?~111, 225-{0010-443-342 s41�54
ART rN 'F*f ID1,10PLAC P S -171 ti11; '701-000-2S 1-600 54.67
ANT) Pi.,.F�_ N (11,WK
1..1:85 PIWTAID VEES
X0.00
TC1'{:Q,._€. I"FRMI"f! 1~ ET.19 ,0 1C NOW
ti'i7 i.33
RECEIPT
DATE
BY,'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
v' 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 3.02% ,J-
F.A.U.
Framing -3 —Ct_
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 (p—J.
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:
7
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 3/20/98 APN # 609-080-013
No. 16773 Jurisdiction La Quinta
Owner NameThe Exchange Group Permit #
No. 43-652 Street Palermo Court Log #
City La Quinta zip -92253. Study.Area
Tract # Lot # Square -Footage 34.
Type of Development Residential Addition No. of Units 1
7
Comments
Adding 34 sq. ft-ot living area to existing construction.
At the present time, the Desert Sands Unified School District does not collect 'fees on gExages/carports, ,covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes.
It has been determinedthe above-named owner is exempt from paying school fees, at this time due to the,
reason:
Residential Addition 500 Sq Feet or Less
s
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount, of
1.93 X 34 ' or $ 65.62 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may n3,.v, ie,issued,
\Ei� )rpt
"
t
Fees Paid By Cash/Anna LozanoTele
y
1
TelepL ;ne '772 0222
wi r
Name on the check
By
Dr. Doris WilsonL�
Superintendent`"
Fee collected /exempted by Juanita Green Payment Received $65b11` 7� L
4
Ch k N Cash
Signature
NOTICE: Pursuant of AssenjKly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protist the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued.or on which they are paid to the District(s) or b another public entity authorized to
collect 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
A