0305-280 (AR)LICENSED CONTRACTOR DECLARATION
46l 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
343335 B C36 CE HIC 0V2&12(
v ....
' Date "'•T � - �� -� 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:
Carver STATE ?13ND Policy No. 22tt.•tM-2003
(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.e
Date: � f" 4 r Applicant
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
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
ttie above-mentioned property for inspec/tioonn.purposes.
ve
Signature (Owner/Agent) f" /'.�//_�'�- " `"" Date 5.�
BUILDING PERMIT PERMTp
DATE Zr r VALUATION LL. 14LOT 03OS-2� TRACT
22 1311K 262
JOB SITE
APN
ADDRESS -M- 310 AVIKHMA .TUAR 2.
I74-233-=
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MAIRi WJORDAN
MLCONSTRI3'G`TfOW .
54- 10 JANI IDA YLIA �
54310 A"�ISTIDA :L -7,
LAQLI. UA CA 92253
L.AQUIlr A CA. 92233
(3 0)564.4447 MLO 2051
USE OF PERMIT
RMllv►1~?3"IRAX AMNION
Tat S.F. M.&STER BEDROOM :AD131TION. 2001 CBC
"9ITION 71-00 SF
.CoY7'nIY' A r'-i,I ( (OST OF CONSTRiCi'M024
FW1 MCK FRE 101.-000-439-m318 $40,95
C;17t+ISTRUCTION FEE 101-.000.416-000 $63.00
ELECTRICAL FEE 101-000-420^- OO $19.50
STRONG MOTION 011t. RKS1I3 101-003.241-000 $.50
MAY, 2 4 2003
CITY.OF LA QUINTA
FINANCE
DEPT.
M-` OtIASL G°tJi .RUC,7TC),ff AND FILM M*C`F.
LE' ► r f -L2AYD 1771.0
6A.i. P1-0 1' ' M s DU STOW
$323,9
RECEIPT DATE %may BYC/_ -1 DATE FINALED INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
f
Return Air
Steel
Combustion Air
Roof Deck0-Q
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
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
2
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
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
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
U61ity Notice (Perm)
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District zq��o
47950 Dune Palms Road
' Q BERMUDA DUNES r i
Date 5/28/03 La Quinta, CA 92253 C/3 RANCHO MIRAGE i=
�
No. 24475 (760) 771-8515 � INDIAN WELLS y
PALM OESERT �
(, LA QUINTA
VO INDDIO
Owner Marvin Jordan APN # 774-233-003
Address 54310 Avenida Juarez Jurisdiction La Quinta
City La Quinta , Zip 92253 Permit # 0305-280
Tract # BLK 262 Study Area
Type Residential Addition No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 22 54310 Avenida Juarez 72 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
r
EXEMPT
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $0.00 X 72 S.F. or $0.00 have been paid for 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 Exempt - Marvin Jordan Check No.
Name on the check Telephone 760/564-6011
Funding Exempt
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon
Signature
ilvrey
Payment Recd Over/Under
r
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 9D -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 permft for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting