0007-039 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9' (gommencing with Section 7000) of Division 3 of the Business and
PrA!es ional�&de, and my License is in full force and effect.
License # Lic. Class Exp. Date
734094 A B ZOIC .. 031314C,
Date *' ° n"`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 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.
),-41' have and will maintain workers' compensation insurance, as required by
SLgction 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 ?.RICK-.AMWCAN Policy No. WC'0322046-03
(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 comp�ith.tho e.provisions.
Date: 7n -11<00 Applicant ci � 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 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.
Signature (Ownerner/�;Ag n j� / ,.r -- Date
BUILDING PERMIT PERMIT#
DA_T,ET) /EVALUATION LOT owl -039 TRACT
25
$14j458.40 28960
JOB SITE '
APN
ADDRESS- spmi= SAY
OWNER
CONTRACTOR / DESIGNER / EN INEER
T HOUM' ,41
H'C.)l�l�M
2%80 WmZ zow C1irC3 . Sum 1 10
2230 WARDI,OW MCLE, I;.'C1M 150
CORONA CIS,. 91720
CORONA CA 91720
(909)279-4000 CC)3L# 5761
USE OF PERMIT
i?�►�3i�f"'i7.PiT, Ai?7.�1"��OA7
SUPPLi«Fd VNTAL TO PERMIT 69909474, .ADDING OPTIONAL MINI SUITE
IN L1P OIC GOLF CART 0ARAOR DURING CONSTRUCTION,
�. 48.00 3F
CUSTOM B014US ROOM CONVE)=.
,S1U .83:+.7.1 COW Or_C0.N i .7U(rAd0
14,4". AO
PERAW.M SWMARY
PLAID CHECK FEE, 10)X000-439-318 $132,14
CONSTRUCTION FEE 101-000-418-000 $162.00
MECHMICAL M, 101.000-421-000 slo.so
HI=TRICAL FEB 101-000-420-000 $21.75
PLUMBING FEE 101.000-419.000 $24,00
STRONO MOTION PEE a RE SID 101-000-241-000 $I A3
ra J r
2 CSM
SUB I OTAL t"ONMUC1109 AND PLAN CIMO :
$360.84•
IX= -PA .tis SEES
$0,00
1 "_►'AL YEW.M' it' 9 RIDE NOW
M0,64
JUL 31 2000
f
U it v T,
✓ S'"' �
DATE
DATE FINALED
INSPECTOR
'RECEIPT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
S?t Backs
Underground Ducts
Fortns & Footings
Ducts
Slab Grade
Return Air
Steel 7
Combustion Air
Roof 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 I I
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 U°' d School District
P.O. Box 847, Thenal, CA 92274
(760) 399-5137, Ext. 235
1
n
This Roy For District Use only
DEVELOPER FEES PAID
AREA:
AMOUNT: RCPT M
CK M CASH:
MIMALS: DATE:
CERTIFICATE OF COMPLIANCE
(California Education Code 1.7620).
Project Name:
Owner's_Name:— entex= omes-
Project Address: 80-562 Spanish Bay, PGA West, La Qui nta,__CA;
Project Description: Residential Addition; Supplemental�to Pem
AM769 .053 005 . / Tract #: .289
Date:
Lot #'s: 25
Type of Development:.. 'Residential XX Comm rcial Industrial
Total uare Feet o m ing Area: 248 Sq. Ft.,
Certification of Applicant/Owners: The person signmg:certifies that the above information is correct and makes this statement
under penalty of perjury and further represents that he/she, is authorize4Ao sign on behalf of the owner/developer.
Dated: 74e
Signature:
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project Agreement Existing Not Subject to Fee
17620 65995 Approval Prior to 1/1/87 Requirement
f
Note:
Number of Sq.Ft. 248
Amount per Sq.Ft. s 3.26
Amount Collected $808.48
Building Permit Application Completed: Yes/No
By: Foch "Tut" Pensis. Assistant Superintendent Administrative Services
Administrator in Charge
1
Certificate issued by:El Sd ESgUedd, Facilities :Analyst signature: aly
NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES AND STATEMENT OF FEES
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) "ritten 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 thefeesimposed is as herein set forth, whether
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
F�