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LICENSED CONTRACTOR DECLARATION
,4 hereby affirm under penalty of perjury 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.
License # Lic. Class Ex _. ate
686895 B
':)1,141
►Date7 Signature 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. 7044, Business & Professionals Code).
( ) 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 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 Policy No.
SUM. >11OR .f AT.10TaA WMr.033A
(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 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
Cgde, I shall forthwith comply with those provisions.
Date: 34141r,4 Applicant
Mh
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 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
correcV1 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. ~'
/signature (Owner/Agent) :� Date �!��•<�
BUILDING PERMIT PERMIT#
DATE VALUATION $%21?S 90 LOT 12 TRACT 211490-7
JOB SITE
ADDRESS, 79-260CITR` US
APN 769-0311-02
OWNER
CONTRACTOR / DESIGNER /ENGINEER
i.iiAi7
&_F'ie4iiii►S#Aiiiv.r
3+100 CENTRAL AVElVUF STP. 32-5
3400 CENTRAL AVENUE 1S`TE 32.5
KI'VERSf:DE 'SCA 92506
fGVERS113H CA 92-506
(909}082-5352 C.HT,4 5-1146
USE OFF PERMIT
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Y
LOT 12- SU1)P..i EMt—r4I'AL 'fO !''Y.TCk-ffT €.9%9-288, IMNOIt+it'1 PLAN 3
'VJ 141,o1N 3.H (W, I' SQU'AKL k00' 1'.P►`. E G'Iiy1.►I GI: ; LIV°1—+63S,-. �+
CO Yrom CONST RUC a 1 0114 .163.00 2
. 331.1 VJ1 A.',D COST OFCONS .RUC,. A �`�.1;!
91203.90
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KAN CIFIR ;(ti FFE 1014)f111 -«139-31R 124AA
1k1ItCt1A _N1('•FiL NU -3, 101-000-.4 1-00()
EC.CC f RiCAL FEE 10i -(W-420-000
STR01401 v(; M(;j'.t'I`7N H - 9ESID 101-000-241-000 5.92
ART t14 K11'iIX", P1, 4(JS - RF81'r 701-004-255-0nf) X73.02
wfTF'j-TrYS�C. ;;.()NSfRf}( 717t f� A�jC►.pl,Q_nJC,;FiFC
RR
$A�7�t7i
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LESS
MI'AAI VERAITIC Fi+,KS Der, Now
X4:17
RECEIPT
DATE
BY r
DA E FIN Ay
INSPECTOR
- C%
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
9d
Underground Ducts
Forms & Footings
0
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
FramingCompressor
Insulation
Gc
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
vC9_21
Drywall - Int. Lath
_
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
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
C.Ow
Encapsulation
Gas Piping
Gas Test
Gtr
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) Elf
COMMENTS:
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515 i
CERTIFICATE OF COMPLIANCE
Date 12/28/99
No. 19845
Owner NameSheffield Homes
APN # 769-690-002
Jurisdiction La Ouinta
No. 79-200 Street Citrus
City La Quinta zip 92253
Tract #
Type of Development
Comments
Lot #
Residential Addition
Permit #
Log #
Study Area
Square Footage 163
No. of Units 1
additional square footage -Grandfather fee paid on prior certificate #19416
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:
Under Mitigation Agreement
EXEMPT
This certifies that school facility fees imposed pursuant to Mitigation Agreement in the amount of
0.00 X 163 or $ 0.00 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be,'isstled
Fees Paid By N/A -Jose Torres TelepBone
Name on the check a
By Dr. Doris Wilson --
r '
i
Superintendent .�
Fee collected /exempted by Olivia Aguirre Exempt $0.00,
Check No. N/A
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9G -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