9602-019 (SFD)tr-" 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.
License # UCACRIISO .13 Exp. Date IWO9!
N; , te2_ 5F 9 Signatureof Contractor i
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 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 workers'
compensation, as proviiledpfor, 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 permit valuation it for $100.00 or less).
() I cdidVttfiatiihi'th''e)performance of the work for whi&ixthfi vipbrmit 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 provjsi'ops. e),
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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. G
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspeccton pur
p
oses.
Signature (Owner/Agent) // 10, . !r'� ,,. Date
mac....
ALC
PERMIT
PERMITS�*
BUILDING
,A
DATEVALUATION
E! 7/!J6
P
5.123.391.."
LOT TRACT -
6 23913
JOB SITE ADDRESS i
APN
�i�_a�aa�' rc,�� � v
' s,at: •a_diva
OWNER
CONTRACTOR
ROGER SNELLFNBERG�?R &ASSOC.
�1 Cpp�f �r 7 p ry per
..•' s1KOG-EIR. Sl1. ,1;i1..1.6:i�ul.f�4L.-',.R_GE�R cl.: ASSC C
l�ii.� vC .tW�r�.t-►C..A�. is
4186313C)ARDI'VALR16212
PALM DESERT CA 922.11
PALM DESERT CA 9221.1
DESIGNER/ENGINEER
(619)777-7766
CHARM D. GARLAND
"
USE OF PERMIT
,
SfNGT,1 :Lala 1i'C6 I'' I YW 1,'LlivG
. 33-163 CATrEDIUAL CAiVYOfJ':". R,
LA'fl OliukL Ci'1' , LA 52234 .
QUINT a- A.
PLAN 2
FEE DESCRIPTIOW
FEES
PIt;�G"1' CONS CRl,. CT10M 2_,!49:00 SF
GARA-00CAPSORT 597.00 ,SF
ESTIMATED COST Of C.ONSTRU "i'i0N
125.391,19
1?LIAN OMECK Ory.
C.oN s`l.'ft11C'C'ta,1N . -x 101-000,418-000
:cr`►A111OAt: k E1 101 -WO -421-000 $53.30
t LEC:11Z1CA:L. FETE 101.001-420-000 $135,60
P1 I"— €-F1F 101-000-419 S154,f)1i
: 'ifONO .i�:€O T:lO1JFEL', . RES115 101-000-241-000 X12.54
ORAIDINGFM 101: -ON 423-000 20,00
114FRASTRC,IC .TURE AM 223-000-443-342
ARM$' IN PLIC ,1C P!,ACES -1 Ii,5JVF701-000-255-000 S70.98
o i`H-TL rAL CONSTRUCTION AND PLAN MECie
S.9;n92.41
LESS PRE -PAID FFrS
$0.00
Face
08 '.T€?TAI,1 ERMIT FEES DUE NOW
$4,692.4.1
1-996
RECEIPT
ATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
W Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck Z
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing PEW74.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath d'
Drywall - Int. Lath
Final
Final
BLOCK Al I APfPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APR VALS
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 14
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP OVALS
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)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 2/2/96
No. 14095
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-273-006
Jurisdiction La Quinta
Owner Name Roger Snellenberger & Associates Permit #
No. 79195 Street Nuevo Drive Log #
Cit, La Quinta
Zip 92253 Study Area 233
Tract # 23912 Lot # 6 Square Footage 2149
Type of Development Single Family Residence No. of Units 1
Comments
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 2,149 or $3,696.28
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
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
i
Signature �� , , aY AA r) ft t a ,tt SNL.
Payment Received � '` ���"$3696.28
Check No. 11027
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
Telephone_
77 66
5!�
� F
ly? e'1
Payment Received � '` ���"$3696.28
Check No. 11027
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