0211-151 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class .^ Exp. Date
W 744091 1: / 1 2p, 1 A
CD OZF_ 015ate .Signature of Contractor ? ►"-"' {{
r`o 0 IOOWNER-BUILDER DECLARATION
�
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ N License Law for the following reason:
Z_ (. ) 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).
M() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O rn
CL Q WORKER'S COMPENSATION DECLARATION
CD ?• zI hereby affirm under penalty of perjury one of the following declarations:
In; Q;W';'.
;J+-1'C)'-'_
�. +-1'C) 'r . (s 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
O=;Q;;r , performance of the work for which this permit is issued.
Cot
Q:O; ;. (•) I have and will maintain workers' compensation insurance, as required by
b-! Q:' „ ;Section 3700 of the Labor Code, for the performance of the work for which this
a • �. "perrmit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier S`'FAI,`F ?dU Policy No. 22942-002V x�f
ao
J (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
3 subject to the workers' compensation provisio"lr s blf Sectio 3 00 of the Labor
Code, I shall forthwith comply Wirth those p e4si • ns.
pate:` in •••'applicant l �' -•..�.
0 ,r01
Warning: Kailure to secure WorkersCompensatlon cove age 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. r
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. t
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursua
any permit issued as a result of this applicaton agrees to, & shall, indeto & hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and v
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancella
I certify that I have read this application and state that the above informati
correct. I agree to comply with all City, and State laws relating to the bui
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for'inspection purposes.
,%
Z
ature (Ownerlwge4l �'�'`' ed
BUILDING PERMIT PERMIT#
51
DATE VALUATION LOT ��-� TRACT
9-12-03 $477,402.90 411*3 28470_1
JOB SITEAPN
ADDRESS 781 137:9 COYt . CANYON f -0�i a
770-2404W,
OWNER
CONTRACTOR/DESIGNER/EN INFER
d.Ri''&1:F)•RY&K.t"k o
SUR VIM D.L:VFLOPMENT iwOWK
3434 W. RMO.r', L
PO BOX 1144
OKLMON11A CM ox 7310
UL QUNTA. CA 9225.'1
(760)771.4722 C di 5393
USE OF PERMIT
.
Lr1Yil. ITAMLMLWG
Z' 701 rXt:l. UL)ItS'WA.t i--dl>OOf MPJVLr'WAY APPROIACWCC+MPIAANCi:V' TFI
ALL i?RDEMAL &:1'1ATR IAWZ 1X(,'%UD1K0 1`HP,1:'1+1D1ltdt3MEM SPI.011;:
ACT OF 4973 W AY1°IXABTX VS 12.iJQt71RZE3
CUSTOM C NSTRUC' ION VD2,00VO
PtX%G:HIPATIO 9:1.00 5F
;R.PACRUCA3 PORT '11063:00 SF
D �''ON11 Ogg' 6�''GD£�S"1"k�.i%1::�'Xi�?N
477,402—'It)
�$1`y �$�' p�y.�f.'J.'t�'.+��:":
.a. �.i.�ia•M::.�'. p.S7 AT�e GYw.rY.1.E( AR
CONSTRUCT19H .E')<.1� 101-M-418-000 $1,:962,50
PLA►A1 CHECK F1 Z 1014*0-4351-3 y 8 $1,400.90
FRE e' POSIT 101-000--439-318 •s11t+4t1.00
MEC'1.3,dtNIC.&L 2rU 101-000-221-000 $.194.50
WiMMUCAL Fiji: 1014000-420.000 33113133
P1.4)MS)Wt3 rME 101-4100-419-000 085.50
STROM 1hl1O T1014 FRE -,RUM 101-000-241-000 $47.14
C812AI)1NG mill 101.000- V23-000 $1.5m
1;iFsTMOPER IMPACT FEE Y2�EU,�,,Rft
ART IN PL)PILlIC PLACIP4.1i° " 1L 270-00"45 000
M R 3'1'AL Cs:rNMit'C.1 09 AM PIA14 CEMCK
M3135.48
MAR 1 3 2003 :c> AL VY',(?Wr1!TLA%'6 UE NOW
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DIE�j t
II I
D!�fINALE D
INSPEC):O
INSPECTION'RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof DeckVI,
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Faris & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Drywall
W-4174
�v
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
— 3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
�Z%-3
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS_ I
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: / q
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 Irving, 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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 5,702 S.F. or $12,202.28 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 CC/Bank of America - Gisela Porter Check No. 20142449953
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected
Signature
$12,202.28 0.00
Payment Recd Over/Under
NOTICE: Pursuant to Government Code Section 6600(d)(1), this II 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 ich the building or installation permit for this project is issued, 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/Receipt Copy - Accounting
4
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
'O REINFORCED CONCRETE O RUCT. STEEL ASSEMBLY O �
C) POST TENSIONED CONCRETE ASPHALT -SRO RO A16j(--w
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION
�]I� (� W p"M t.4
1`'�1
REPORT SEOUENCE NO.
TYPE F T�U EGGYY77 ��J; � ,n � .1`�
IIV�j jR[,�v_
PERMIT NO.
�' ��
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
IZrTOR
HRS. CHARGED
'I Q t
s n et•Lq +
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL SUB��,�+
CONTRACTOR U CONTRACTOR
AP uk-CA qJ
3 a7
p S �"tiel l3'b S��. I �rss ec.� Ion csv,, COLA-- cam- S.jt,
CoftAa�07
kx- --c es
190-0
COPY SENT TO CLIENT O
CONT 0 ON NEXT PAGE ❑
PAGE Of
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF My
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS, SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
gIjNATLjhE OF REGISTERE SPECTORc1 moi,(
1311 Q3+� `) �o X 1, L'
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