9512-011 (SFD)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. c4.J'3;1 $ 12/3/95
License # Lic': CI -ass r Exp -Date
DateSignatureofContractor._ \ .
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, 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).
O 1, as owner of the property, am exclusively - contracting with licensed
contractors to construct the project (Sec. 7.044, 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 maintaima 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 wh"ich this peimit 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.
(This section n . d not be completed if the permit valuationjs J $ 00.00 or less).
() I certify dtlin tris 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-provisio�s.
Date: klAv, k C 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 3708
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 undevor pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of In fi, l4A, els itsio(iii rs, 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 ofvwork for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. 1, 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 forinspectionpurposes.
Signature (Owner/Agent) C --'�'' +� � Data k!Z.+Sk!r!
ALC "
BUILDING PERMIT
PERMIT
011
951
DATE • 12/419.5
VALUATION.2L+ LOT 62
TRACT 23913
JOB SITE ADDRESS
APN
79-090 000TILLO ;D' UVE
604-262-018
OWNER,
CONTRACTOR
R:OGFR S'NEL FIN13ERCi R cASS
ROGM S'RELLENBEMIC-,it,;C;ASS
41865 BOARDWALK. #212
41865130AR.DW:ALK #212
PALM DESERT CA 92211
PALM DESERT' CA 92211.
(61"1 77=7766 CSL# 1858
DESIGNERIENGINEER
(619)777-7766
C_E[ AnES D. 01I.RLAND
33-.163 •C.AT1�DRAL C'A'N DR.
USE OF PER60SINGLE FAb'T Y DWELLING
of., &T gyp_
C, 1tlI.%i'1'F.RRA
PLAN t
FEE DESCRIPTION
FEES
'MACT CIONSTRUCYIGN 1X8.00 SF
G.ARAGMAIZPDX1' 583.00 SI'
&STEVATED COST OF CC)litSTR€ MOPi
113.2R9.2i�
IJF ,MIT 1+'UE SUMMARY
PL;t1N C F� CK";FFE, 191-000-439-318 $595.43
qoN rtuari'1NTE1s 101-000-413-000 $706.00
MTCHA ICAL FM 101-004-;121-000 X63;50_
MF. '17111CAL,.F ]0'Z-090-4201100 $144.04
PLUMMY MY .FIX 10I-(?at1-419-00 $150,00
S"i 03+i't i�1tYi'IOtJ T � - R EStU 1004?J0-241.000 $11.83
C3RA1jTNc#::1. E1; 101,-ODO-423-000 $20.00
1M-R.AS'1'RLrC"TURE ME 225-000-443-347
ART 'INPt71zl,ZC PLACE- 3.Mir,, 701-000-2554M $69,22
SUBIT'OTAL CONSMUCTION AND PLAN CHECK
X4,385.53
LESS -PAID FEES
suo
.PRE
'U
F TOTAL PERId11 E, ES DUE NOW
' ;MO.53
JLC 0 7' 1995
RECEIPT
DATE _1 .
BY
DATE FlNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
L
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
UqU79Compressor
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
FinalI tv Vp I N. UE
BLOCKWALL A PROVALS
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'APP
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:
Notice:
Document Cannot Be Duplicated
Date 12/5/95
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
No. 13934 Jurisdiction
Owner Name Roger Snellenberger & Associates
No.
7908.0 ° Street Ocotillo DrF. i
City La Quinta zip 92253
APN # 604-262-018
La Quinta
Permit #
Log #
Study P rea 233
Tract # 23913 Lot # 62 . Square Footage 1968
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 Codc 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. "v
Fees Paid By Roger Snellenberger & Associates, Inc. Teleuhone '7'77 7.766
Name on the check r
By Dolores A. Ballesteros
IN,
Superintendent (rr; , 44 '� >
Fee collected /exempted by Pauline Pearson Payment Received $3.,384.96
n Check No. 10308
Signature 1\ c Plt t a �aP U� 4 �.�t oj�•_
Collector: Attach a copy of county or city plan check application form to district copy for all wamvers
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting