9601-006 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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. 4R�234 13 l,2/ 3/95
License # U C ass 1Exp. ate
Pate 1TgSignatureofContractor �/
OWNER -BUILDER DECLARATION
I hereby affirm 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 Gode).
( ) 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.
(This section n.g.gC1 not be completed if the permit valuationis.for-$100.00 or less)..
()Ice
At in fi�the performance of the work for whichthispermit is issued,
1 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 pr sions. /� /�
Date: & 14_4_Applicant 2 /( i. �!/n !o
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 resu of this application agrees to, & shall, indemnify
& hold harmless the City o di `I eils(�I).s 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 pur oses.
Signature (Owner/Agent) Date /_
!
"""
BUILDING PERMIT
PERMIT
DATE 113!9,6
VALUATION SJ 18,289,2C LOT TRACT 23913
J08 SITE ADDRESS +
APN
,7! -200N% EVO D:KtV
04-263-023
OWNER
CONTRACTOR
ROGER SNEI:LENBERGER & ASS
R.OL�1?R SNC• Ll,;EMBERM & ASS
41865 BOARDWALK 0212
41865. #212
PALM DES1;Itt" CA, 92211
PALM D :SEIrr C.A. 92211.
t'6l.9)777M/66 0131..0 18.%
DESIGNERIENGINEER
(019)7'77-7706
CHARLF5 D. GARLAND
33-163 C!VfM RAI. CANYON DR..
USE OF PERM 11NG:LF FA.M1LY DWELLING
''TRACT
QUINTISRRA 239:13'VIBASE H
PLAN 1R ,
FEE DESCRIPTION
FEES
TRACT CONSTRUCTION •1,968.00 S1:
GARAGMAFiPORT 583.00 SF
FS-10".TED COST 01' CONST;1d1JMON
:11.8,289.20
PF, MIT FEt;:.i'itMAI A.RY
.PLAN MECK FEW, 101-000-439-318 $59-43
CONSTRUC'.1 IUN FHE: 101-000418-000 $706.00
M C''if1ANICAL Fly, 101-600441-(M $68.50
ME'CTIUCAL ELZE 101-000420-000 $144.14
.pl:(RV-03ING F93 1.01-000-419-000 $150.00
STGNG MOT ION FE - RESID .104-000-241-000 511,33
0RADING 1?U 101-000-423000 $20.00
[NFRAS'1'RUCTUR.E FEE 725-000-.143-342 52.661.51
tMKT l:I PUBLIC" PLACES - Rt St{; 70.1.-00o.2S5-0Q0 ?2'3'.22
a,
SUB -TOTAL CIONSI RUC'170N AND PLAN CHECK
MX5,53
LESS PRE -PAID FEES
1
TOTAL 1P.EMW P'.EjES DUE NOW
i
$9,385.53
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING A
PROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings g I rDucts
Slab Grade
Return Air
SteelCombustion
Air
Roof Deck
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
BLOCKWAI
l/
PP OVALS
POOLS - SPAS
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
f
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
Final
Utility Notice (Gas)
ELECTRICAL
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)
0PAOVALS
-
COMMENTS:
Pl;,tice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
61 U_77S_'%C%(1(1
CERTIFICATE OF COMPLIANCE
Date 1/3/96
No. 14001
Owner NameRoger Snellenberger & Associates
APN # 604-263-023
Jurisdiction La Ouinta
No. Street See Below
City La Quinta Zip 92253
Tract # 23913 Lot # 8&57'
Tvpe of Development Single Family Residence
�.v�iiw�ut.f
Permit #
Log #
Study Area 233
Square Footage 4100
19-200 Nuevo lir. x1968 Rr 79-130 Ocotillo Dr. @2132.
No. of Units 2
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 1.72 X 4,100 or $7,052.00
the property listed above and that building permits and/or Certificates of Occupancy for
this square footage in this proposed project may now be issued.
Fees Paid By Roger Snellenberger & Associates s .` Telephone, 777=7766
Name on the check
r4 r
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received ,$7,052.00
Signature k ( ; Qy nn n Ln /u n A Pyv�
Check No. 10634
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
4