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9703-013 (SFD)
LICENSED CONTRACTOR DECLARATION I 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 Exp. Date 361.2 81 2!.29/"93 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. 51' ATE 11 UNI) 1413 J23411 (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 Code, I shall forthwith comply with those provisions. 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, indemnity & 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 fromdate 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: Signature (Owner/Agent) Date PERMIT # CONTROL # BUILDING PERMIT 4 t't�,3-�3�.3 '4783 DATE3/ W"r VALUATION LOT TRACT ADDRESS "20��tlM Cd,l.l)� 31)A,.KEZ ' JOB SITE APN 7734.14-001 OWNER CONTRACTOR / DESIGNER / ENGINEER Dot 1Ci.E.AS G far, 1"f'1Itfi i�it::T3'.ri'`a'� BUi1,D1MS, 71-898 HI(YHWAY .111 ) LA Q1►11?i FA (-'A 92253 {ra3.9� b s 9 AY.P. 4W USE OF PERMIT , SRO 8rv-P!-71biflT 1(W"LIJIIUXsS M? GARDEN 'tiJA;U, AS SHOIaf 4 O �U1X'I' L a, • 1.,6803.i)o S. k"<..ff,ZCtiJI'e1.E�t4J 1. `FG.t1l1 tSH <�Altt\f..l:;/-rii:tt7%fit.'1' �uG.t)II:S 13t.iN,'X W.A(X CHT/1,F) 9.,7Stt.00 VAYCOIS COINS Ruc. HON PERMIT SUMAIARV C(X4S' 1Z0f_7J0N T'IA 101-000-4115-t1!`)U . xv PI -AN CITCK VIFT,. INI C:'t:iANIC;AL-M pl:-000,- 2 f -000 x53.;uo n! XC114JCAi.. FHE 101-000-420.000 51.3:2.2:2 FUMIOtt�►INO. FM tO t -000-4'19-000 S128.75 rn S t t31e!'1 � Nlat'JON FES - IMSID 101 000 -*241 000011.,W WO O rMi _ 101-000-423-000 5220.00 l+o"-RA,Tr.wor,;nmrin- 225-000-443-342 S2 VI.28 - "_° .10t-000744045 Q .ivlr,r KPURLIC TILAC :'S -11E',,317r, 7017000-255-000 53x.59 Mail) Pr.,01 Q.tEC;K ��,�15.2 ESS 'I"MA,.4'+�.tst#.I 1?II:;V 1:8i)"F:NCiyi' RECEIPT DATE BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR 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 — /y q 7 OF Compressor Insulation 5 —71 — -7 Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath sr — 7- -7 Final Final POOLS - SPAS BLOCKWALLIAP WovALY steel Set Backs Electric Bond Footings Main Drain Bond Beam —17 05eApproval to Cover Equipment Location Underground Electric Underground Pibg. 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 A O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection I Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final 7/1 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) P.O: BOX 1504 �7&105 CALLE ESTADO APPLICATION ONLY Buildings.. // __ _ Q Address (�i � •%?''`�. • � ; , .. LA QUINTA, CALIFORNIA 92253 0 .- O / 3 -•^� Owner , ` �b� ug Ian �-�R� r✓ F ►-h� City Zip Tel. '�" ' Address 0. E3 ox t 43 y City Zip Tel.. - State Lic. City & Classif. 5R> 6 22 Lic. # 00-7 (109 Arch., Engr.; Designer 17Q1111"e % Address Tel. P,D— e, 50 7 S 323 - 3 31 JJ CityZip State , PA -L SP(zI N 16 q 22 6 3 Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7010)of Divisie 3 of the Business and Professions Code, and my license is in full force and effect. i SIGNATURE DATE �! OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis - for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 17 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, Buisness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.) I: I I, as owner of the property, am exclusively contracting with licensed contractors to con- struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) 171 1 am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified c py1hereof. (Sec. 3800, Labor Coge,.) Policy No. Compan), rs LN,Cbpy is filed with the city. ❑ Certified copy is hereby furnished. _ ins Z3'7 23 q (R . ,5.TR T� Wrvip• 1.AIS r10J) CERTIFICATE OF EXEMPTION FROM - WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation 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. BUILDING: TYPE CONST. OCC. GRP. A.P. Number -713 — I I Lf—.0o I Legal Description 14:1f /3LK ;t S-.1-1IR �✓ fir + o/�oSS Project Description s /! t a 41M 11,4 r e.s i d_AA Cr.e- Q Sq. Ft. `4 go Size New 900 Add O No. No. Dw. Stories I Units Alter ❑ Repair ❑ Demolition ❑ i / 511- U' QheX bqg- b Estimated Valuation /Os -,000 PERMIT Plan Chk. Dep. Plan Chk. Bal Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure AMOUNT e TOTAL REMARKS Date Owner NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become ZONE: BY: subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances: comply with such provisions or this permit shall be deemed revoked. Front Setback from Center. Line Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line I hereby affirm that there is a construction lending agency for the performance of the . ` work for which this permit is issued. (Sec. 3097, Civil Code.);Side Setback from Property Line Lender's Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out, signed and validated, and is subject to expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct= 1 Issued by: Date Per I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives sof this city to enter the above- mentioned property for inspection purposes. Validated by: Signature of applicant .- Date r t FEB 3 1997 Mailing Address 1 Validation: City, State, Zip BUILDING DIVISION Ike CITY OF LA QUINTAL - CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING 1ST FL. SQ. FT. @ $ 2ND FL, SO. FT. POR. SO. FT. Ca. GAR. SO, FT, CAR P. SQ. FT. WALL SO. FT. @ SQ. FT. @ ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation BONDING FLOOR DRAIN MECHANICAL FEES FORMS WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER GAS (ROUGH) GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED OTHER APP.IEQUIP. LAUNDRY TRAY AIR HANDLING UNIT CFM TEMP.•POLE KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE, TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. ® c BATH TUB SQ. FT. © c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID @ 11A c SEWAGE DISPOSAL SO.FT.GAR @, 3$C HOUSE SEWER REMARKS: VENTILATION GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL, AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP.IEQUIP. REINF, STEEL GAS (FINAL) TEMP.•POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. $ plus x$ =$ LUMBER GR. FINAL INSP. FRAMING FINAL INSP. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL Desert Sands Unified School District Notice: 82-879 Highway 111 Indio, CA 92201 Document Cannot Be Duplicated 619-775-3500 CERTIFICATE OF COMPLIANCE Date 3/13/97 No. 15326 Owner Name Douglas Griffith No. 51620 Street Avenida Juarez City La Quinta Tract # Lot # Type of Development . Single Family Residence Comments APN # 773-114-001 Jurisdiction La Quinta zip 92253 Square Footage Permit # Log # Study Area 114 1680 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 1.84 X 1,680 or $ 3,091.20 the property listed above and that -building A' permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued Fees Paid By cc/Pomona First Federal Bank & Trust/Mohave Telephone -34_-1-3949 Buffdets .- - Name on the check w . V By Dr. Carol McGrew �'% �" • �' Administrator in Charge Fee collected /exempted by Pauline Pearson Signature Pal J -„A 4, Pa A 1 AA—.04-t-, Payment Received $3,091.20 Check No. 1010017 40TICE: 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 protest the fees or other payment identified above will begin to run from the dale 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 .,,actthem on the Dislrict('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