0210-039 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions. of
Chapter 9 (commencing with Section 70001 of Division 3 of the Business.and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
car" 2(
ate Signature of Contractor
OWNER BUILDER DECLARATION f
-a
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:
( ) Xhave and will maintain a certificate of consent.to. self -insure. for workers'
co ensation, 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 work.for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier S9`A�f �'UWO Policy No. 1.242T)3-02 �. .
(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 tPt a rov' io `
Date: � Applicant—i.-'
larnsinfVFYurre to secure Wor ers'Compensatio�coverage.is unlawful and
ubject an employer to criminal penalties and veil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for: ,a permit subject to the conditions and restrictions set forth on hisD
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and' employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of.issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the. building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fFt inspec on purposes.
ignature (Owner/Agent) Pte—7
_ BUILDINGS PERMIT PERMIT
DATE, " VALUATION I�,y� s�yp,ryryLOT: TRACT
...
ADDRESS. ` �. AO
-
APN
174-2.1.4-02,6
ALL C it i.
OWNER
'CONTRACTOR / DESIGNER / ENGINEER
WN, C401MLAST
VY.iJLFY C.OMRTI , T:OX
54025 AV1 ADAI&M -0
5�t8ffiClti' . Ai.11At t�l}U r>a;y
TA QUMA. OA 92253
TAQLiWTA OIs h
.:
(760)364-4844E�k"1+ 191
USE OF PERMIT
IMMIDT IAL AL DY.130111 '
,439 51t ROOM AX)DITIONPER ,P*,PYb4TC".V= PLk14
TRA- CT COMT13UC ION 41I<S►,i7i1 ff
PORCIVPATFO . 66.00 SF
0.t ;WCARPOiVr. ft74,00 9�'
_ 0b.'Tr OJr C01�I�r'°�'.RUC'1'�CCiX
G. + ,y��,'tEy�$T'.T€b',PA°I".�:3A
y +!' �:v.
dC X ' JLC �X� AL L �7r6.fA72.cv'i f� R ..
03TRi CYLON FEE 101 � 000-41 B-000
P, CHECK FEE 101-000.439.315 "
k9IsCiT"lc kL FEE 101-000-421-000.- S39.10
ZTRI AL FEE 1€11-000-420-000
1'taUA�i�1lifl�L' ��=UC3q^�1�R x.00
a -MO. MOTIom pu - T ul= 101_-0i&24'1 -000
e ,
ZA
JUL 07 CON27RUCTION AND PT" Cf W, CK
$778.81
CITY OF LA (.1UINTA LF.8S PM -PAZ) REM
FINANCE DEPT .
1100TAL P900T rMS IRTE NOW
RECEIPT
DATEBY
DATE FINALED
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 6 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap G
F.A.U.
Framing _ O
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall•Firewall ,
Exterior lath
Drywall - Int. Lath
Final
Final 4'
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 (Penn) 76
COMMENTS:
}. CERTIFICATE OF COMPLIANCE ;��F1EDse
` Desert Sands Unified School District' 4�c��
1 47950 Dune Palms Road
' C BERMUDA DUNES r
Date 12/10/02 La.Quinta, CA 92253 rn RANCHO MIRAGE d
I
No. 23946 (760) 771-8515
PALM DEELLs
ti
PALM DESERT
Il LA QUINTA
' . � INDIO
Q` ®;' y
Owner Don Jones APN # 774-21.4-026
Address 54-025 Avenida'Velasco Jurisdiction La Quinta
city La Quinta Zip 92253 Permit #
Tract # Study Area
Type Residential Addition No.�of Units 1
Lot # No. Street S.F. Lot #, No. Street S.F.
Unit 1 54025 Avenida Velasco 499 Unit 6
Unit 2Unit 7
Unit 3 Unit 8
Unit 4 ^b Unit 9
Unit 5 _ Unit.10 ,
Comments
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 living, 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:
Residential Addition 500 Sq Feet i or Less ,
'
EXEMPT
This certifies that school facility fees imposed pursuant to,
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $0.00 X, 499. S.F. or $0.00 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 Exempt-Anette Jones Check No.
Name on the check Telephone '760-861-9367
Funding tExempt
By Dr. Doris Wilson
Superintendent
y
Fee collected /exempted by Monica~Guillen 1$0.00 .=
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will 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 date on which 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
owl
`, Certificate of Occupancy..
,V
��--
5T • ��'ll�'Ij�
T? 4
',
'i z
19U
0 Building & Safet Department
Y
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance., this structure was in compliance with the
provisions of the Building Codd- and various ordinances of the Cit regulating building
y
construction and/or use.
BUILDING ADDRESS:-54-m *VEN'B* VEEAEJ'�
-TI-Its C'&tuz Ca II-L-A /k4��
Use classification: CASITA -Building Permit No.: 0210-039
Occupancy Group: R-3- Type of Construction: VN Land Use Zone: IRC
f
Owner of Building. DON C JONES Address: 54-025 "ENIDA VELASCO
�F
City, ST, ZIP: LA QUINTA CA 92253
1 4
xR
By: KIRK KIRKLAND
Date: 10-3-2003
Building Official
14
T
T,fl
POST IN A CONSPICUOUS PLACE