9601-005 (SFD)l
LICENSED CONTRACTOR DECLARATION
I hereby affirm 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. 488234 B - 12/3/95
License # Lic. Class Exp. D }e:
Date_ SignatureofContractor r
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) I, as owner of the property, of 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).
O 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 `� SignatureofOwner
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'•compensetion insurance carrier & policy no. are:
Carrier Policy No.
(This sectI.�Fo/r�eQd(rfotEK� completed if tike permit valuationdr;,fgfi 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 thho�se/!rovisio 1 /7
Date: t (�Applicant
7/ A !,�
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 resultl.o�f this application agrees to, & shall, indemnify
& hold' harmless the City of li die(A'Wd g '. As 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, andhereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
Signature (Owner/Agent)/ lam/.+. //% Date. 1 ` !V—
VALUATION 'PAA #,rAaa•wvl LOT
JOB SITE ADDRESS X4-576 OCOTILLO DRIVE
OWNER
ROGER. SNIvLLEMBERGER cit ASS
41863 BOAR WALIK #f212
PALM DESEWT CA .92211
(6193)777-7766
USE OF
QUIN TEFJ..A - TRAC7.23143 PHASE' If
PLAN 1'R
PERMIT06014)05
—I _ TRACT
APN 604^36.1_012
CONTRACTOR
ROGER SN.ELL:ENBER—GE t &ASS
4.1$6S.13OA.RbwA,T.K. 0212
PALM U.ESERX C.A 92211
(619)777-77656 CBL#f 1858
DESIGNER/ENGINEER
C4iAP.I.ES D. GARLAND
33-163 CAM DRAL CANYONI DR.
`rR ACT CON4TRUC'.f ION 1,1168.00 SF
GAR&OFIC.ARPORT 583.00 S:H
US7'iMATEI D COST OF CONSTRUCTION
8:18,,20.213
PERMIT WE SUMMARY
PLAN C,t• 6CK H'3
10140100-439-318
COINSTRU("'L'ION FEE
101-060418--000
$706.00
IViECYLANICAL HE
101.000-421-(3401
S69iso
ELECTRICAL FILE
1.O I -000.420-0()()
$144.04
PI;tjMRtNC
10! -000-419-000
$150,00
S'1'UivvMOTION FM- RFI SID
100.000-70-ploo
X11.8.3
0RAD1'AiG FEE
101-000423-000
�2fi.t)0
1NF'RASTItUGF R2f?:FEE
225-()00-443-342
$2,661.x1
AK r 1?? PUBLIC PLACE,S - Rbq1B 701 -300 -VS -0000
M."2
,S.UB-TOTAL CONSIRUCTIONr AND :PLAN CHECK. I $1,385.53
LESS PKE-PAID FEES $0.00
7'tD` 11 mmn."I:r ul s, Du E'Now $4j385.53
RECEIPT I DATE I BY (DATE FINALED I INSPECTOR
a/\
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE .
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
z
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
BLOCKWA
V t
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
COMMENTS:
Final
Utility Notice (Gas)1,94-
ELECTRICAL PP OVALS
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)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 6-19-775-'500
CERTIFICA'T'E OF COMPLIANCE
Date- 1/3/96
No. 14000 Jurisdiction
owner NameRoger Snellenberger & Associates
No, 44570. Street Ocotillo Dr.
Citv La Quinta Zip 92253
APN # 604-263-012
La Ouinta
Pe -mit #
Log #
Study Area 233
t
Tract # 23913 Lot # 19 Square Footage 1968
Type of Deveiopment Single Family Residence No. of Units 1
Comments
At the present • time, the Desert Sands Unified School District does no. collect fees on
garages/carports, covered patios/walkways, residential additions under 500 sq-iare 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 1,968 or $3,384.96
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. r ''
)Fees Paid By Roger Snellenberger & Associates _ Telephond 777-7766
Name on the check
By Dolores A. Ballesteros
Superintendent -'
Fee collected /exempted by Pauline Pearson Payment Received $3,384.96
Signattarea 20 P.1 u A
• Check No. 10634
Collector: Attach a copy of county or city plan check application form to district copy for all w givers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Coov - Accounting