0107-008 (AR)OWNE01-BUILDER DECLARATION
,rl herej�y �-iii�'rn"6��Ier,'penalty,of perijuliy that' I'am exempt from the Contractor's
1, as owner,o the property, m employees with wages as*their sol6
contracti licensed
contractors to 'con st ruct,.#�e' project; (Sec."7044 7 BuSi6i�s Profes'sio'nals
,I am exempt -under Section B&I?C foirthis reason
.r" WORKER'S COMPENSATION DECLARATION
li,; I.; hereby affirm, under, penalty. of perjuryone,of the following declarations:
naihta-in a certificate f consent to self -insure for workers'
�,T compensation,, as provided for. by Section 3700"of the Labor Code, for the
-k, I have and willjiia.intain Workers' compensation insurance, as required by
of tl�ie Labor Code,, for -the perforrhance of the work for which this
Policy No.
(This section need hot be completed if the permit valuation is for $100.00 or less).
I certify that inthe perforriiance of the work for which this permit is issued,
1.1.1�shall hot employ �ny person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
e wo ers' compensation provisions of Section 3700 of the Labor
C6de,'- I shall forthwith comply with those provision
!�P�arning:, Failure to secure Workers' Compensation coverage is unlawful and
!i�all kjbject an employer to criminal penalties and civil fines up to $100,000, in
!-'addition td'the t of c6mpensation, damages as provided for in Section 3706
Cos
'6f the' Labor Code, interest and attorney's fees.
, 41MPORTANT Application is hereby made to the. Director of Building and Safety
fo (,:a' permit subject to the conditions and restrictions set forth on. his
_Eac�`pe�son ulion whose behalf this application is made & each person at
rl Whose - request and for whose benefit work.is performed under or pursuant to
'a�.y permit issued as a result of this applicaton agrees to, & shall, Indemnify
khold hirmless the City of La Quinta, Its off Icers. agents and employees.
'2.,Ahy permit Issued as a result of this application becomes null Bind vold,',If�l
work Is not commenced within 180 days from date of Issuance of sud.h.L;4'
�ermlt, 'or cessation of work for 180 days will subject permit to cancellatio 4
II
I certify that I have read this application and state that the above Information
correct. I agree to comply with all City. and State laws relating to the buildl
constructlon, and hereby authorize representatives of this City to a t r. up
the above-mentioned property for Inspection purposes.
Date I
'
47
OWNER iti
CONTRACTOR DESIGNER EN INEER b. i
k!v, V
11-9 C.M1190RIN10
1152-4105 A0A1fflPAV_q
USE OF PERMIT
FIERAPPROV ED PLANS
TRAr"T CONSTRI)CTION 41"A.1 BF
0ARAGWCARPORT .071.00 SF
FM
CONSTRUCTION ITE 101 -00-418-000
P11fiJ1 CHECK FU
u?'.
Klwrrwq�L. on,
STRONG MOTION FEE. RJUSUD 10 3 FJOO-24 14160 'Scso
LZ
Mg
MAL
NOV 21 2001
14
cay Of: LA
'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
z BUILDING APPROVALS
MECHANICAL APPROVALS
_
Set Backs I � Z f7,Q3_� i
Underground Ducts
Forms & Footings I
Ducts
Slab Grade ) (�� �`
Return Air
Steel t
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap 1
F.A.U.
Framing ] /
Compressor
Insulation I �='6 03 � <
vents
Fireplace P.L. 1
Grills
Fireplace T.O. 1
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath i G_
Drywall - Int. Lath I
]
f
}
Final
Final ]
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings I
Main Drain
Bond Beam ]
Approval to Cover
1
Equipment Location
I
Underground Electric
f
Underground Plbg. Test
Final I _
Gas Piping
PLUMBING APPROVALS
Gas Test
_
Waste Lines I p�
Electric Final
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Outl
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral ]
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping
Gas Test
Appliances ]
I
Final
]
I
COMMENTS:
I
Final ]
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole i
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures
Main Service I
Sub Panels
Exterior Receptacles
G.F.I. ]
Smoke Detectors ]
Temp. Use of Power
i
1
Final I
-
-
Utility Notice (Perm)
Desert Sands Unified School District
47-950 Dune Palms Road.
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 11/20/01
No. 22694
Owner NameM/M Manny Costa
No. 50-900 Street Calle Obispo
APN # 770-104=006
Jurisdiction. La Quinta
Permit #0107-008
fLeg #
city La Quinta zip 92253 Study -Area
Tract # DCT U5 Lot # 86 Square Footage 479
Type of Development Residential Addition No. of Units 1
Comments
ion is an utility room of 479 sq.
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:
Residedtial Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 479 or $ 0.00 the property listed above. and ±hatbuilding
permits and/or Certificates of Occupancy for this square footage in this proposed project may now b issued
Fees Paid By EXEMPT - Manny Costa Telephone- 408=234-3574
Name on the check
By Dr. Doris Wilson .
Superintendent
Fee collected /exempted by Annette Barlow
Signature 4. !4
Exempt $0.00
Check No.
JOTICE: 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 protest 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 to 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