0304-115 (SFD)H
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury,that I am licensedunderprovisionsof
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and�eifect: ' -
License # Lic..Class Exp. Date
652. I i0 ,s :t1ff Elt'!:Y' ;
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Date ��• ,T 'Signature;of Contractor•
OWNER -BUILDER DECLARATION
hereby affirm under penalty of'perjury'that l 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 r' a.
WORKER'S COMPENSATION DECLARATION,
I hereby affirm under penalty of perjury one of the following declarations:
O I have_:and will maintain a.certificateof consent to self-insure'forworkers'
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 workfor which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 'affA I,,, C'C+MP Policy No. ',*V7; -G!
(This section need not be completed if the permit valuation is for $100.00 or less):
O I certify that in the performanceof the work for which this permit'is issued,
I shall not employ any person in anyTnanner id'as 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 witt`hose provisions:' y j
Date: ! + Applicant
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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 3708
of the Labor -Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the,Directorof 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, &rshall, indemnify
& hold harmless the City of La Quinta, its officers, agents .and employees:
2i 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.] 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) i� • > r�'= Date, `!
BUILDING PERMIT ?ERMITI
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INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE -TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
SetBacks69 ry
�111001e��
Underground Ducts
Forms & Footings If
Ducts
Slab Grade
Return Air
Steel V(-
Combustion Air
Root 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
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice,,(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole XCI C,7
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke, Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Comments
At.thepresent time, the Desert Sands Unified School District:does not collect fees on garages/carports, covered patioslwalkways,, residential additions under
500, square'feeL detached';accessory structures (spacesjftat do not contain facilities for Irving, sleeping, cookin ' eating or sanitation) or replacement mobile
homes. It: has beemdeterminedIthat theebove-named owner is exempt from paying schooi4ees atthis time due to the`following reason:
EXEMPTION NOT APPLICABLE
This certfies thatschool facilityfees imposed pursuantao
Education Code Section 17620 and Government, Code 65995 Et Seq.
in the amount of $2.14 X 1;615 S.F., or $3,456.10 have been paid for,the property'listed above and .that
building permits and/or Certificates of Occupancyl6r this.square footage in this proposed project may now be issued.
Fees Paid By OC/EI Paseo .Bank - Paulden Evans Check No. 851658556
,Name on:the check Telephone
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by
Signature
Funding Residential
Payment Recd $o.00
$3,456.10 Over/Under
NOTICE: Pursuant to,Govemment,CWwSecU n 66020(d)(1), this wifterve to;,notify you that the 90-dayapprovahpenod'in which you may,protest the fees or
.other payment identifiedr above will begin to run . m.the date.pn which the'.building or installation permit,for this prolectis issued; - or from the date on which
those amounts are paid toahe District ii) or to another public entity authorized,to collect them on the District('s) behalf, Whicheveris earlier.
NOTICE: This Document NOT VALID'if'Duplicated
Embossed Original - Building DepartmenUApplicant Copy- Applicant/Receipt Copy -;Accounting
Ce tifoca to af'OccupancY
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car,
oF9 B-ufldng &Safety Department
This .Certificate. is issued pursuant to! the ,requirements: of Seddon, 109 of. the 'California: Building
Code, certifying that at the time .of issuance, this structure was- in compliance .with the
provisions of ;the Building Code .and the various ordinances of he ;City regulating bu►ldng
construction and/or use,:
BUILDING ADDRESS • 53-765 AVENIDA ,CORTEZ'
Use classification: SFD ; Building Permit No: 0304-115 .
Occupancy Group A R3 Type- of Construction: VN Land Usa Zone: RC