0305-001 (AR)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
Date 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 84 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&RC, for this reason
Date i, e /,. ,/ 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.
(This section need not be completed if the permitvaluation is for $100.00 or less).
(l certify that in the performance of the work for which this permit is issued,
I sal1 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 Sectio 700 of the Labor
Code, I shall forthwith comply with thosf: provisions !V
Date: 4 . /:Applicant
Warning: Failure to secure Wo d(ers' Compensation Coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in .
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes•.
Signature (Owner/Agent) Z�✓ �' = "—,,-Date 1=-A .Z�
BUILDING PERMIT - PERMIT�ry# t
,.
aJ.$i3 'C9�.Y
DATE ' - ,VALUATION �"- LOT ' TRACT
't r 4 -
JOB SITE ' /'
APN
ADDRESS ! -137ANIZMANia VATO.ZC0
774 -0M -0i9
OWNER
CONTRACTOR / DESIGNER / EN (NEER
JO8.FI RIODR101w, : , :.
O NFM, / BUMIYFIR.. .
p) 37 A fIV ANAVAM e
LA QV1A�3"! A CA 97.25
'
C - c
USE OF PERMIT
CONV'E'RT EX.13"PIN0 0ARACE 7'i7 F.tIrS.' R 00MfAD 9V'LW TWO CA.R Cf132.t3GE r1'
S TOR.A09 ROW
CUSTOM k3CiNUS ROOM 01�',y14V'FJ 110.00 V :
a?a.nn SP
ESTI V.IiAM-1 CONT OF C()XS1117Z1)C 1CkX
I5,W1991.40
PXTMrr lipSTJWMl8,&Y
PIAN CHECK FXH�
CC1'AtS'rRUC1'ION FX %, 3 (!f -(342(1-�t) $—i3C $171400.
MECH&NICAL $28.00
F-,LN.,CTRIC'.FSL. FSE �':., eta-� ao �rrc3 ' *32.0
FMO
$0,00
MAY 0 l 2003
CITY OF LA gUINTA
.
-DEPT. r ;07
RECEIPT
DATE�r A --
By-,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -5—/-
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck —
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing ,d
Compressor
Vents
Insulation
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
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:
r1e-.n A, <, _. /-X
3`l?. -O�( �a
/
l
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)
Bin #
�;.�� City of La Quinta
Building 8t Safety Division
Permit # P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
1� Project Address: ,6 137 Au F. NAuAC943 Owner's Name:
iOP. i
A. P. Number: Address:X37
Leg�1 VE . tga
Legal Description: Cite. ST. Zip:
Contractor: FTelephone: 76o �7'7/ 3�2
A Address:
Project Description:�� � ,��� Q,.•,,��
1� Cit,•. ST. Zip: �
K Telephone:
13i A Al .
A State Lic. # : Cin• Lic..'-':
Arch.. Engr.. Designer: ZAU to
Address: _ JVb�- _ N�UA P-100
City. ST. Zip: Ic Q
Telephone: 76r3 6f I 4-7.7 C> Construction Tye:
p Occupancy:
State Lic. #: Project type (circle one): New Add Alter Repair Demo
X Name of Contact Person: K:s Sq. Ft.: #Stories.•
23 S r # units:
X Telephone # of Contact Person: - '`" b stimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#FPlan
l Req'd Recd TRACK NG
PEIi�11T FEES
Plan Check submitted /Item Amount
tructural Calcs. Reviewed. ready for corrections 3
Plan Check Deposit
Truss Calcs. Called Contact Person
Plan Check Balance
Energy Calcs. Plans picked up
Construction
Flood plain plan Plans resubmitted c�
14 N1ech:nical
Grading plan 2"" Review. ready for corrections/issue
AL3 Electrcal 3Z
Subcontactor List Called Contact Person 1 001710 Plumbing
Grant Deed Plans picked up
SAI.l.
H.O.A. Approval Plans resubmitted
Gr d'
M HOUSE:- 'n° Review. ready for correctio ssue
e eloper Impact Fee
Planning Approval Called Contact Person
A.I.P.P.
Pub. Wks. Appr Date of permit issue
School Fees
Total P*rmit Fees
14 CX
j L%
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District X4.0:0
47950 Dune Palms Road Q BERMUDA DUNES r
Date 5/1/03 La Quinta, CA 92253 Cn RANCHO MIRAGE, d
{r INDIAN WELLS ti
No. 24386 (760) 771-8515 `�,�nP LA QUINT ^may
INDIO ` J
Y Q Y
Owner Jose Rodriquez APN # 774-054-019
Address 5313TAvenida Navarro Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # 0305-001
Tract # Study Area
Type Residential Addition No. of Units
Lot # No. Street 'S.F. ....Lot # No. Street S.F.
Unit 1 53137. Avenida Navarro ,110 Unit 6, ,
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments Converting existing garage to bedroom.
s
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 (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
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 110 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 - Jose Rodriquez. Check No.
Name on the check Telephone 7601771 -3624
'
' Funding Exempt
By - Dr.` -Doris Wilson
Superintendent '
Fee collected /exempted b On MCGllvrey _ $0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), thl W 2 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 isiissued, 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/Receipf Copy -Accounting .
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