9709-060 (RER)LICENSED CONTRACTOR DECLARATION .
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaf ler 9 (commencing with Section 7000) of Division 3 of the Business and
Profeg"o,,onals Code, and my License is in full force and effect.
License # 61c. Class Exp. Date.
t �r�
DateSignature 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. 7Q44, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting,wi'th 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:
Carrier i 7,t+"Y • Policy No
(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 sh II 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 5 Section 3700 of the Labor
Code, I shall forthwith comply with those pwrovis 01'
/Date:; Applicant—l"r-40
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 fo, & 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`trepre�n dtives of this City to enter upon
therabove-mentioned prope fo inspect(O, purpo s-^"
f
/Signature (Owner/Agent) Date
BUILDING PERMIT PERM IT�q,�1,�#;� CONTROL#
' 5902
DATE n VALUATION + LOT TRACT
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ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JASiti'ftNHO & 11�.1111 ZAII'M, 1[0.80
GUSTAII•SOV CO IN -SW}t:1` 01M
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SEP 12 1997 TULA!, PERMIT PEWS OUK NOW'
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CITY OF LAi. QUINTA
RECEIPT
DATE
By�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
S 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
F.A.U.
Framing ,A &2
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
BLOC KWALL A PROVALS
POOLS - SPAS
steer:,
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::
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201 `
619-775-3500
CERTIFICATE OF COMPLIANCE.
Date '9/12/97 APN # 604=264-005
No. 16076 Jurisdiction Palm Desert
Owner Name Jasminko & Snjezana Beso Permit
No. 79085 Street Ocotillo Dr. Log #
City La Quinta Zip' 92253 Study Area -
Tract # Lot # Square Footage '250
Type of Development Residential Addition No. of Units 1
Comments Garage ,Conversion to bonus room
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in ``.he amount of
0.00 X 250 or $-0.00 the property listed above and that -wilding
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid By n/a-1530Telephone ` 772
Name on.the check
By Dr. Doris Wilson
_ Superintendent
Fee collected /exempted by Pauline Pearson Exempt ~$0.00
Check No. n/a
Signature 1.9 �1 /Yyyvl
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 proles: 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
collectthem 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
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