9703-078 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury'that I am licensed under provisions of
.CHdpte;9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # y' Lic. Class Exp. Date
57
Date/4- 5 .11 nature of Contra . o
i/ .11g
nature
CLARATION
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).
O 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 woikers'
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.
TAT" F0 : i.2r'tAl '
(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 ecor, a subject to'theI
workers' compensation laws of dtalifornia, and agree hat if%I should become
subject 1011 a workers' compensation pro isions of Sectio 3700.of-the�Labor
Cea s iall•f_orthwith complyyI th se p vlslonst`
Date'J'`7 APPIic �it�
Warning: Failure to secureEZkers' Compensation cover ge isunla ul andshall subject an employer tohinal penalties and civil fines u to $100,000, in
1P P $
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
correct I agree to comply with all City, and State flaws relating to the building
construction, and hereby authorize representat' �� this City to enter upon }
the above, -mentioned property fo insp$ction urp ses. $
Signature (Owner/Agent) Dates
BUILDING PERMIT PERMIT# CONTROL# 970.3-07N 7
0
DATE VALUATION LOT!9TRACT "
$,426.40lI 13:.1,K,193 VIX,
JOB SITE 'l�
ADDRESS 5.�,-TSAVEN.If.ik .IUAREZ
APN
774-103-023
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JOEI :�1 i XFf :I:r Sl2
JorF,, 94.r. S mmmr.m'2i?, lit, cot -1, T'.
42315 WASHI7efGPO Si :9355 -
42335 WASHING 1•Q1�3 ;� r.133���
-:PA.LNI 0Ei81:ikT CA 92211
PALM DESERT CA 92260
•
(7Gt3}i�,Sf�9�f� .. Ci3i,:'� 2119
USE OF PERMIT
SM ei Wq 260 L.F., 6i WOOD V +.1 CE r iT D080 NOT INC%.iSt7.e
IALOi:K WALLS
'1'I��� x' tr.���;a rltilC'I'dLltt I,G:tO:t)tt fi
Fel``-JFt!„'I."i1'.t1"f'iC:) �iE4.lffl �f�
Cila34iL3`iFs{taill2'i�I�'.(' 410.00 S.t%
+i 1 l`. We7t D [ HNC'6 200.00 LF
UeSTIMA11,A) CONT OF CO -INSTRUCTION
",426.40
PERM 11" 01 SUMMARY.
CIt>`r'NSTRUG1't,0NK*14 $639,50
l,!MN CK I.F. lU l {l d.„x y3:t 8 $ps_�1"4.77
gqrflfi/;
NfECHAMCAI`,T'EL . 101t)P 421-00a
,R_ ,F F1UCAY k . 101 -000 -420 -cel) 5329.10
PLt7WYNO, RIS $In s)
S' ONO? M0—Tr0N M - RES -11D 1401-000-241-000
e i eiL�l? C1I;'i 101-000-4.2.3-006
f”3df'RA,%1"ii1Xi'tJT2t5:41r5 22:5-000-44-4•3I2 2.d 8.4t3
I?C -?',i.A1`t
jd
SUWT'%)' A' , C:OJS"I�UCTION AND PLAN 1"`!1VX .I4
$3,7n-79
LE SIS 90&E -PAID FJEES
-$250.00..:
MAY 05 199T.• .: :..
:
rIT-07 A. -P,
r JE, ' fBY
DATE FINALED
INSPECTOR
:
��
': E.." 5 Nee r ...
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
- -L q 7 Ali
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
F
Compressor
Insulation
L -Z o --a
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
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
- L / — 7 Q
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
11 vt 1
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
Fixtures
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
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 5/5/97
No. 15487-
Owner
5487Owner Name Joe Stemmer, Jr. lk
N0.53725 Street Avenida Juarez
City La Quinta
Tract #
Lot #
Type of Development Single Family Residence
Comments
APN # 774-103-023
Jurisdiction La Quinta
zip 92253
Square Footage
Permit #
Log #
Study Area 111
1640
No. of Units 1
verpayment of fees. Check amount $3473.79 tees $3017.60 KEFUND $456.19
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 1,640 or $ 3,017.60 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project way now, be issued
Fees Paid By American Savings Bank - .Teleph6,ie 360-9365
Name on the check +;
By Dr. Carol McGrew,
Administrator in Charge
Fee collected /exempted by Pauline Pearson Payment Received $3,473.79
(� Check No. ?
Signature �
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 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
.,,actthem 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
Z-1PrN'n- 7770791 F03
SCHEDULE A
Your Ref: 97.6436 KC
1. The estate or interest in the land hereinafter described or referred to covered by this report is:
A FEE
2. Title to said estate or interest at the date hereof is vested in:
WILLIAM R. RILEY, TRUSTEE -OF THE WILLIAM R. RILEY TRUST
3. The land referred to in this report is situated in the State of California, County of RIVERSIDE
and is described as follows:
LOT 11 OF SANTA CARMELITA AT VALE LA QUINTA, UNIT NO. 19, BLOCK 193, IN THE
CITY OF LA QUINTA, AS SHOWN BY MAP ON FILE IN BOOK 19, PAGES 33 AND 34 OF
MAPS, RECORDS OF RIVERSIDE COUNTY, CALIFORNIA.
7/93bk
m
c�.�'i � z Zi ea ��,y, r �i:'✓+3'} *..,� - _ - _ ... _- -• •- . •vw.w...*.-tet .
, 't 0ACHELA`VALLEY WATER DISTRICT `
_CASH RCCEIPT DETAIL
rrelved.From:��t'YlY1�G�Q.
areas: Ltd=335 x f'�t1!'N ;4 5&7, TALM
p 1
count:No. ylOtlsi 1 .LCL- 193 Trac
rvice:Address �'/ -' a/Z r 1- ;GA. Code
"Servlcelsl
xt` ;a
*kmlow(s)
iHouse:lateral(s)
etector Check(s)
�+teterSu�charpe ti; � - ^^�
r - i• rte: �'i.1.•1.
;SanitationCapad Charge*.
W S.S.F.C•
#4 n mry construction Meter
,tTurn on Charge
U_ Uncgllected Account -Name
peolion*Fee -Tract -
-a'3r ue WFee- y P
Checkl`iye 1 Water / Sewer
_.Aract - . rr.
Ym at - 4 D TAssmt—
tomer Deposit r.POW% t:
TOTAL $
l
j,copy to:
Dash' s : Water Service
theck
ItAoney -Cashier
T._ CVWD-438(111e9)