0009-116 (SFD)LICENSED CONTRACTOR -DECLARATION
1 --hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profsssionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
ate AQ 4 Z4 4, Signature of Contractor
}- OWNER -BUILDER DECLAR TION ;
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 tomconstruct the project (Sec.• 7044. Business & Professionals
Code). ;
() .1 am exempt under Section B&P.C. for this reason
Date Signature of Owner11
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.
(a) 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- sued. My workers' compensation insurance carrier & policy no.. are:
Carver '•: Policy No. -
(Thies ction 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 tho'se:provisipns.
Date:- /9.. 25'-. 6e Applicant—
Warning:
pplicant / A �a
Warning: Failure to secure WorkersCc pensation coverage is nlawful 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 isnot 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 inspe tioh purposes.
1
Signature (Owner/Agent A�' �� ��wd'j Date
BUILDING PERMIT PERMT#
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS
4 ::::OWNER CONTRACTOR/DESIGNER/EN INEER
PCS.BOX 297 73.300 #UMUMMY. 're
I_M D OW R. ' CA 92261 MUDRWAT CA 52261
(760)837,1
USE -OF PERMIT
SFU a PEP—MIT F. 012, 140T FN CLYA6?k, 8 f..f1CX '%VA 4, /P(X..)L /S.P.A, DP
D.WTVAYAPFROA, CH
TRACT CONSTRUCTION 3L4'.rlO, rig , ••
PORCH/PATIO t4 8's.00 SF
-41'"I°, WOOD FENCE 1209100 LF
p�.1��W7MIAT'ED COSSM OF CON51113MM&3R
&.jkkAS'�rn.tb.��?.DAa f7rliAY.dldXl�d'i.$ '
CONC11TR:UC'I`ION .GYM 10) � J>418.000 $621,50
PLAN CHECK ";S. 101-,000-439-318 U145,51
MEPCIR MC:AL IEEE. 1.01-000-421-000 $56.00
Y4J?CT9JCAL IvEt' 101-000-420-000 $111,81
PL[lMTHO PRE 101.000.419 -OW
S',PRUMO MO":1014 FRE - I gSiD 101-000-.241-000 $9.60 ,
ORAM1< O FU 10) -000.423.000 $20,90
09VeSl.OPER IMPACT PRE&
PRECISE PUN 101-000-441-345 b la0.0A
FEE Wlposrr 101-000439-319
f ,
SU.r,-'- TisM 00101 t1i11014 AUD PLAN OkWX $3,458.1 "a
TOTAL PJMM F=5 VUX NOW
RECEIPT DATE 'p �, BY DATE FINALED . INSPECTOR
i t
.00
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
5
Underground Ducts
Forms & Footings
S��
Ducts
Slab Grade
_
Retum Air
Steel
_((�
Combustion Air
Roof Deck
`2 �p- Off'
Exhaust Fans
O.K. to Wrap
Framing
F.A.U.
Compressor
Insulation
(2� ��4�
dj�
Vents
Fireplace P.L.
( Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
67
Final
Finale/�
/
l
��
O`
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
�2, (?�p0
G,�%
Electric Bond
Footings
.tel
Main Drain
Bond Beam="+!
'✓
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
/_ f
Heater Final
Water Piping
_
_ •D�
I
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
COMMENTS:
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)
Building
Address
Owner
Mailing
Address
'City
Contractor Vr'
T4'ht 4 4 "
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Tel.
City (f r ) ,iAA o0
Zip / Ji�c� 1
T�) 7O` — 13<1 C
State Lic.
& Classif. �-�
City ,
Lic. q
Arch., Engr.,
Designer
Address
Tel.
City//,
rl. f / ^P --F
State
Lic. If 7w► 1
LICENSED CONTRACTOR'S DECLARATION
I hereby aflir that I am licensed under provisi f ChapIaJ9 (commencing with Section
7000) of Divisio 3 of the Business an profession-s�Code, tic ns in full force and
effect. I, s
S GNATt1R n DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5, Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to'its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis '
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
!: 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I l 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
r7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work -for which this permit is issued, I shall not
employ any person in any mannQr so as to become sgbj ct to the yJorkers' Compensation
Laws of California. �S%
Datener oma((
NOTI E O APPLICANT: it. of r making this Certificate of Exemption yo shoultl become
subject to the Workers' Comp nsation provisions of the Labor Code, y d must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county orginances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of adplicant Date
Mailing Address
City, State, Zip
AP2PLICATION O2NLYA
BUILDING: TYPPjE'CONST. f"� OCC.GRP.
A.P. Number /) 3" P(/ - J
200
Legal Description 4� 03 ? &C,' - ?yq 40
Project Description
4!4/1 8a0 QLA AL
�.
S',1 X53
Sq. Ft. No./
Size Stories /
No. Dw.
Units
New>' Add ❑ Alter ❑
Repair ❑ Demolition ❑
1
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot'Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 10/25/00 F APN # 773-174-003
No. 21136 Jurisdiction La Quinta
Owner NameJim Belknap Permit #
No, 51-800 Street Avenida Velasco Log #
City La Quinta' Zip 92253 Study Area
Tract # Lot # 3 Square Footage 1554
Type of Development Single Family Residence No: of Units 1
Comments SFD
A
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::"�
' • >- f` ,�C t lam• . ti.. � "' e
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.05 , ,, X 1,554 of & 3,185.70 the property listed above and that building y?_, f ,
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued ,
Fees Paid By cc/Wells Fargo/Bill Belknap Telephone 760 772-1345
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Olivia Aguirre.. , Payment Received $3,185.70
Check No. 7377002521
Signature
w - -
FNICE: Pursuant of A sembly 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 .
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 Disthct(s) or to another public entity authorized to
t them on the District('s)(s') behalf, whichever is earlier. -
Collector: Attach a copy of county or city plan check application form to -district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
Certifi
cafe of Occupancy
Citta-
y.of LaQurn
} .
Building.. and Safety. Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code, -
certifying that, "at the time of issuance, this structure was in compliance. with the various ordinances
of the City regulating building construction or use. For the following'.
BUILDING ADDRESS: 51-800 AVENIDA VELASCO
Use Classification:. SFD Bldg. Permit- No.: 0009-116
Occupancy. Group: R 3 Type of Construction: VN Land Use Zone:, RC `
Owner of Building: JIM BELKNAP Address: P.O. BOX 297 ;
City: PALM DESERT, CA 92261
By: -STEVE TRAXEL
Date: 02-08-01.
Building Official
POST IN A CONSPICUOUS PLACE