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0007-038 (AR)LICENSED CONTRACTOR DECLARATION J hetfebyaffirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and i Pr fesstonals Code, and "my License is in.full force and effect. License # Lic. Class Exp. Date 7340 AE 1 Date " Signature of Contractor t r? 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). ( ) 1, 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: () 1 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. ho)„.l 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 ZUpjC .,WVR1CAN Policy No. IC83212045-03 (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 •with°th'ose &dvl'sions. ,r Date: '"Al ?.t -e`.f� Applicant-�. lir A° _ - 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 ancrrestrictions set forth on his application. , a 1: Each person upon whose behalf this application is made & each person at el whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicator 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 inspectionpurposes. Signature (Owner/Ag Date -~ BUILDING PERMIT PERMIT# DATE �VALUATION LOT 0W'7_08 TRACT A1C IM5.30 50 28960 JOB SITE i APN/ ADDRESS W..5' 5 cSPA MW DAY Q /� �&/ f ©� lJ05 OWNER CONTRACTOR/DESIGNER/EN (NEER I✓MIUKHO.IV 0 COWOC i �ti"WHA 2:2W WAIDT,OW C@?CL E Bt.UM 150 27,80 WARDLOW CWCU, �, SUITE 150 CORONA CA 91720 CORONA CA 91720 (905)279-4000 CEIR 5761 USE OF PERMIT R&EWKWMAL ADDTY1ON SUP1PLMMTAL'TO MRIVIT 09909.279, ADD1140 OPTIC1NA.f., MINI SUITE 2 rH LIEU OF GOLF CART 0ARA09 C UR1190 CONSTRUCTION, CUSTOM B014US ROOM C014VE-1 244,00 3'F CUSTOM CONSTRUCTION 19.00 SP, W IA1!W COST OIP CONSTRUCTION 15,70.S30 .PRRUV FEE SUT.t+D+X RY PLAN CHECK FEE 101-000-439.318 $136.33 CONSTRUCTION VU 101-000-418-000 S1111.00 MECHANICAL PEP, 101-000.421-000 519.549 ELECTRICAL IZ9 101-000-42:0-000 $12.75 PLUM91HO IRE 101.000.419.000 918.00 TRO140 MOTION FEE - RM -ND 101-000-241-000 *4¢ BUD -TOTAL CeOA'B'I::RIX ION AND PIAX C DMK $365.15 IMS PRE -PAM FM $0.00 To-rNOW V615111% t JUL 31 2000 , .�IOF L " QUINA RECEIPT DATE,DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings j Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans 0. K. to Wrap F.A.U. Framing Compressor Insulation U U 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 O.K. 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 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: .�Coachella Valley Un' d School District F ;, P.O. Box 847, The al, CA 92274 ' This Box For District Use Only CERTIFICATE OF COMPLIANCE r (California Education Code 1.7620) Project Name: � c Date: ' Owner's Name: en_ _ex_ . omes Phone No.. 90 279-4000 Project Address: -535 gpanisfi Bay, 'PGA West, La.=Qui nta, CA 92253 "77 ProjectDescription: Redidential "Addition, Supplemental to Permit .#99"09=278 ' APN: 769 053 005 Tract #: 2R Q Lot #'s: 50 Type of Developme Residential - XX Comm rcial Industrial a o uilding-Area: 244 Sq. Ft. ; x I Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement under penalty of perjury a further' represents that he/she is authorized. sign on behalf of the o er/developer. Dated: Signature: ' SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN N OR WILL BE SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE).,;. Education Code Gov. Code Project v Agreement Existing Not Subject to Fee 17620 65995 } Approval Prior to 1/1/87 Requirement . > Note. Number of Sq.Ft. _ "244 ` Amount per Sq.Ft. S I K261_ Amount Collected s 795.44". Building Permit Application Completed: Yes/No By: Foch "Tut" Pensis: Assistant Superintendent Administrative Services a.A.dnainistrator in Charge Certificate issued y: E1,94 .Esq ueda, Facilities Analyst Signature: NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES STATEMENT OF FEES Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written notice to the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day period to protest the imposition of these Fees and (2) the amount of the fees.' Therefore, In accordance with section 66020 of the Government code and other applicable law, this Notice shall serve to advise you that the 90 -day protest period in regard to such Fees or the validity thereof, commences with the payment of the, fees or performance of any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether •Y payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date hereof. This Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School District, and up to three (3) such extensions may be granted. At such time as this Certificate expires, if a building permit has not been issued for the project that is the subject of this Certificate, the owner will be reimbursed all fees that were paid to obtain this Certificate of Compliance. Rev. 09/27/99 DEVELOPER FEES PAID AREA: AMOUNT: RCM N: . CK b: CASH: INITIALS: - DATE: CERTIFICATE OF COMPLIANCE r (California Education Code 1.7620) Project Name: � c Date: ' Owner's Name: en_ _ex_ . omes Phone No.. 90 279-4000 Project Address: -535 gpanisfi Bay, 'PGA West, La.=Qui nta, CA 92253 "77 ProjectDescription: Redidential "Addition, Supplemental to Permit .#99"09=278 ' APN: 769 053 005 Tract #: 2R Q Lot #'s: 50 Type of Developme Residential - XX Comm rcial Industrial a o uilding-Area: 244 Sq. Ft. ; x I Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement under penalty of perjury a further' represents that he/she is authorized. sign on behalf of the o er/developer. Dated: Signature: ' SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN N OR WILL BE SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE).,;. Education Code Gov. Code Project v Agreement Existing Not Subject to Fee 17620 65995 } Approval Prior to 1/1/87 Requirement . > Note. Number of Sq.Ft. _ "244 ` Amount per Sq.Ft. S I K261_ Amount Collected s 795.44". Building Permit Application Completed: Yes/No By: Foch "Tut" Pensis: Assistant Superintendent Administrative Services a.A.dnainistrator in Charge Certificate issued y: E1,94 .Esq ueda, Facilities Analyst Signature: NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES STATEMENT OF FEES Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written notice to the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day period to protest the imposition of these Fees and (2) the amount of the fees.' Therefore, In accordance with section 66020 of the Government code and other applicable law, this Notice shall serve to advise you that the 90 -day protest period in regard to such Fees or the validity thereof, commences with the payment of the, fees or performance of any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether •Y payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date hereof. This Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School District, and up to three (3) such extensions may be granted. At such time as this Certificate expires, if a building permit has not been issued for the project that is the subject of this Certificate, the owner will be reimbursed all fees that were paid to obtain this Certificate of Compliance. Rev. 09/27/99