9604-064 (SFD)(LICENSED CONTRACTOR DECLARATION��
,%ereby affirm,under,penalty of'Iperjury tl4at l/am licensed under pr`ovis"ons 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: = ;y
License # Lic..Class ' Exp. Date
4 Date 4 1 10 .Signature of :Contractor
OWNER -BUILDER DECLARATION" '
1`hereby affirm under penalty of perjury that l 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). '
() lam exempt under Section. , B&P.0 for this reason '
Date - Signature' of Owner
- .. y.
WORKER'S COMPENSATION DECLARATION
I hereby affirm- under penaltylof .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'reguI. cl' 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:
Cartier Sof M—bFUND Policy No. Q63.559,
(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. person1in 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 witli those provisions...!,
Dater 4 1f-A/r;:,:' Applicant ". s
Warning: Failure to secure Workers' Compensation coverage isunlawful,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 -&e alch 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.
JY ,f,'s 'p ...t. t • r
Signature (OwnWAgent)Date '�z �•
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BUILDING PERMIT PERMIT# CONTROL#
BUILDINGPERMIT.
531 18
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USE OF PERMIT `
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RECEIPT .,,
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD %.`
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings W t44Ducts
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final f i6 1W
POOLS - SPAS
BLOCKWALVAPOVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
P MBING 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)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
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 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 4/17/96 APN # 604-262-021
14340
No. Jurisdiction . La Quinta: '
Owner Name Roger Snellenberger & Associates, Inc.
,Permit #
No. 79150 Street Octillo Dr. Log #
City La Quinta zip 92253 Study area 228
Tract # 23913 Lot #' Square Footage 2730
Type of Development Single Family Residence No. of Units 1
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 Code 53080
in the amount of 1.72 x 2,730 or $ 4,695.60 J
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'.'
Fees Paid By Roger Snellenberger &Associates, Inc, Telephone X777 7766
Name on the check
By Dolores A. Ballesteros T4
Superintendent ;. 9
J
Fee collected /exempted by Pauline Pearson, '-Payment. Received $3,495.60
Check No. 11830
Signature ,�0 0 �nV ( ➢�10i� 1(10Y1/�_
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