9907-404 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of,perlury 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 & 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 maihtain.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 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
D1tewith th
/1�Applicant'J���
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
the above-mentioned property for inspection purposes.'
4riature (Owner/Agent) ' �� % Date ✓/��
BUILDING PERMIT PERM'T�;.
DATEf �k.tt�I�.�(AVALUATION �'�aE�R.�iRJ. LOT. �f1�RACT 'esy ,1yi
JOB SITE
ADDRESS
7.6949b 07
;r t
OWNER
CONTRACTOR / DESIGNER / ENGINEER
O'rI'tI 7'Ai\!�± L !`0. JLFA.1`7`t•'.'��r'l7 '�
( iAT�fTi L':. fil'Ci'!Al i�'i//' Y!ni!"'
P10 B0,1K 1490.
i s9W AVENUE45, SUr—'; C
l.A.,QUI1s1TA. CA 922153
I D10 CA.
C°ltiff1,iRl�!-a34y8 C��.C,,ft tt'7
USE OF PERMIT
S!NtIX f�rkk11kf.A )Ni:LfNG
-
,i
N..
1 EDI ONLY • O titUK VAUS OR.POOL. lSs- Oµ'0Q PER, � -
1997 U KC §Y)4_5 F'Olk WORK WAAJT PIRRM1'. PLAN C H.I;X;K.I=f: l
til i ►s 9£ i fs 73%, FVOR fV1 A:'lIP F� ISSUr'#1'JM
TRL ACT C.`.C.YNSTII.UC,T]O.d 3,27.8.00 SES
T•'e��'KC',EIlI':�:1�2R:i r�ig.t�U fir•
-
0E1lC;>,+::)&GAA2kPORT 79:2.(sU '3.rb
ESTL ST -01\8 TION
PERMIT F;e11 suhlyr kv
C:ODMITMI fC ION FEE 10140)418-000 �9`�3.t➢Cl
PI. -AN
ITTE .T:sI, MMI T Int, f�UO rt 9^318 6: 30.t3i1
l iLtEu�hliC,` ..FETS `to1-00-421.490 $?33'.30
lxi.. C,ih'iC'F11. E'� S 1111.-1#ttfi-420-000 $22J.6a
P9,iM3TN0 FIEF; 301.6t(kt-4194W 60lt%3
.y'1'ji4.11ETG, MOTION.ISE - I2.&SIi7 .101-000.241
URAE)W,13 F—LE 10A 40 -423 -ON
DEW, OPHR IM.PAC;I' 3 -EE 6t, 907,00
AT21^ IN f'+T_fBLIC, Txf,As ER, _ Idp'_:Ii` 7411=000-' +5-4)00 $252-15
1iy�VESTIC:<Ai';ON,M- U; S0 ai0_11226_Wl; $993.4
1.I13-1 i"Al CON sol KtfC`.'i`!L3N AIN Us P LAN CHEX-1K
vt,892 25
LESS PRE. -PAID RES
2 510M,
.P.V.
J �•�F is
.-V..N
.T8OPPM. LY
gES. LP NOW,$4.642
,,RAaI
.2 5
RECEIPT
DATE
By/
DATE FINALEIYINSPECTOR
5113163
INSPECTION RECORD
OPERATION
DATE
j
OPERATION
DATE
INSPECTOR
BUILDING
+Set
APPROVALS
MECHANICAL APPROVALS
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
+Set
APPROVALS
MECHANICAL APPROVALS
Backs I
Underground Ducts
Forms & Footings 1
i
Ducts
Slab Grade i kol
Return Air
-Steel
Combustion Air
Roof Deck ;
O.K. to Wrap }
--� �`�
v
Exhaust Fans
F.A:U.
Framing }
—6—op ST
Compressor
Insulation i
Xtra 157
Vents
Fireplace P.L. }
Grills -
Fireplace T.O. }
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Laths
--
D II - Int. Lath I
I
Final
Final }
POOLS - SPAS
BLOCKWALL
AR .ROVALS
Steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam }
Approval to Cover
}
Equipment Location
I
Underground Electric
f
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines i
Heater Final
Water Piping I
t I
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral 1
Pool Cover
Sewer Connection }
yp p -o S
Encapsulation
Gas Piping I
Gas Test 6
Appliances I
I
Final .
I
COMMENTS:
�t l.�o B,s, 1 -cam
}
I
Final } .
Utility Notice (Gas)
ELECTRICAL_ APPROVALS
Temp. Power Pole 1 77:72 • Q a
Underground Conduit
Rough Wiring }
Low Voltage Wiring
Fixtures I
Main Service }
Sub Panels }
Exterior Receptacles
Smoke Detectors I
Temp. Use of Power
Final )
Utility Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 8/23/99
No. 19229
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN # 769-063-007
Jurisdiction La Quinta
Owner NameBCK Investment Group Permit #9907-404
No. 50-900 Street Paloma Court Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # 76 Square Footage 3,279
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:
i
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 3,279 or $ 6,328.47 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 CCB of A/ Jay S. Gary Telephone _770-8860 _.
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sylvia Carrasco Payment Received $6,328.47
�J � � Check No. 2016566132
Signature ALLG�.�/�/�( �
NOTICE: 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
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check appNcation form to district copy for all waivers.
'Embossed Original- :3uilding Dept./Applicant Copy - Applicantf.Receipt Copy - Accounting