9903-314 (AR)LICENSED CONTRACTOR DECLARATION
,I herebv affirm under penalty of Periury that I am licensed under Provisions of
cii$ter 9 (commencing with Section 7000). of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
t Licen.5e # Lic. Class Exp. Date
74_3867 BE o
tD4 rr/� 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 Jor 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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(
)J 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
subj�ci to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall ort with comply with those provisions.r
„ D`ate: 0 1+ 97Applicant - � -�
Warning: Failure to se , ee Workers' Compensation coverage is unlawful and
shall subject an employes to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
:IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a'result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from. date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and .hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
1�
/,gnature (Owner/Agent) ` Date A
�., • ,, -�
PERMS#
BUILDING PERMIT
S1`�
DATE f VALUATIONS,637�$ LOT TRACT. I-!
JOB SITE
ADDRESS '%9-06 AVIENIDA LATOR �
APN �2tc�a
rl�iE%-11Q -1PtW
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PO BO :132 i
P013OX .13U7
PAA'., N1. DESiiRT L.A. W24155
PALM. D SIEU G.A. 92255 .
f76f11`)77:)-^1571 C;Ia 3028
USE OF PERMIT
RE� )EXTIA1 ADDITfON
75 S.F. Eli. DITICYU TO 17-1 IUSE 0MM CO.NS'i`1iUICTION (P' UD 't; KrFTR O . ,
IN W IS1'I)NO 3RD CCK U11f1..P1GE)
;t k
�v!'i.LC1P1.7..'I%grol X637.00 LS
Mq.UAT ED CWF 01F WNST."IlUCTION
KAN Ckf 'C.K IFFF3 101-000-A39-318 $3e.lU
c,0NSTTP(,—rac)N 10111(x)-4194100
f%4r-. 1,'GtMd A1J .T 1.03 11!10-4 .1-C43t! $21.50
l'.I.4 tEd1f 3f N�f .1 kil 1.f> 4 {tt}i)-d i � A1(?U $33.00
IS�Tl3;fC9YN(3`kfCYf1()T,tFt7.1.1' ;tr) if1iCE/�1}t�yf(�)-Jd*i_!ryf(I!1 ."�t1
@
2,6 5,-000-
Aid INjuK10' KsN. '1sS- RE= 701 -000 -255 -ow "W's -9
5±°i,1k3-�11+Q.�l�N),I<4JlN.Li.A�fV AND PIAN, 0.'C11»C_l.ti.f)7
LESS PKF,—PA1D FEES.
$0.00
TOTIU, PF, 11' FEES #)UE t�ispta�'
$'E2�.6i9
R IPT /
DATE
DATE FINALED
INSPECTOR
T '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL'APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation _ ,S,
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 Plat ?71?POOLS
BLOCKWALL APPROVALS
- 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 4 `i
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:
r Notice:
%
Document Cannot Be Duplicated
Date 4/1/99
No. 18526
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameWorld Development Inc.
N0.78695 Street Avenida Las Torres
Jurisdiction
APN # 769-144-004,
La Quinta
Permit #
Log # '
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 75
Type of Development New Residential Addition
Comments laddit. to house under construction
No. of Units 1
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'folioWr'n,g,
reason:\�� f
EXEMPTION NOT APPLICABLE
Government Code 53080 in the amount of
This certifies that school facility fees imposed pursuant to ,i
1.93 X 75 or $ 144.75 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 cash Telephone 771-5571
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Adriana Gauto Payment Received $144.75
n n t Check No. -
.
Signature
NOTICE: Pursuant of Assembly 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
above 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 District(s) or to another public entity authorized to
collect 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