0306-301 (SFD)i
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Divi6on 3 of the Business'and
Professionals Code, and my License is in full forcWand effect.
License # Lic. Class // Exp.,Date
74619€3 1la C'W
21 L-6 Signature of Contractor
OWNER -BUILDER DECLARATION l
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
1 -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.
( ) 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:
Cartier STATP. AIN Policy No.
(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 m f her so as to become subject to the
workers' compensation laws of Califor I and agree that if I should become
subject to the workers' compensation p ovisions of Section 3700 of the Labor
Code l shal forthwitp comply with.t s�fprov ions. -"""
Da teb :" ;!'Applicant c,,.
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 perso
whose request and for whose benefit work is performed under or pursuan
any permit issued as a result of this applicaton agrees to, & shall, indemi
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi i
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellati n.
I certify that I have read this application and state that the above information is
,correct. I agree to comply w'(h all City, and State laws relating to the building
construction, and hereby a`�tyiorize regesentatives of this City to enter upon
the above-mentioned prop r�, for inspection purposes.
Aid.
Signature (Owner/Age d'A - Date
BUILDING PERMIT PERMIT#
;f1
DATE VALUATION LOT'. TRACT
'1 S
JOB SITE
ADDRESS!
APN
OWNER
CONTRACTOR /DESIGNER/ EN (NEER
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JUL 2:2003 TO�g�.�� T FrX'N DAM NO
CITY OF LA QUINTA. .
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECIGIp
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Combustion Air
Roof Deck
Exhaust Fans
OX -to wrap
F.A.U.
Framing
S p
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 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
B b
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 AR
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Date 7/18/03
No., 24724
CERTIFICATE OF COMPLIANCE
Desert Sands Unif2ed School District q�cS�11U�o
47960 Dune°Palms Road
- Q' BERMUDA DUNES r
La Quinta ZINDIAN CA 92253 v) RAN (-J ;
. {� AN WELLLSS WE"ter
.
(760)'7714515 di� PALM DESERT ,y
V LA QU INDIO
o
Owner Roy Schubert APN # 773-134-024
Address 79025 Via San Clara Jurisdiction . La Quinta
City La Quinta Zip 92253 Permit # 0306-.301
Tract # 0306-301 Study Area
Type .Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # , No. Street S.F.
Unit 1 12 77730 Calle Sinaloa 1519 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 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 unde"
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:
EXEMPTION NOT, APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14X 1,519 S.F. or $3,250.66 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 isstied`
Fees Paid By CC/Palm Desert National Bank - Chris Lloyd Check No. 087,645
Name on the check Telephone 760/771.3053
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collecte
Payment Recd
$3,250.66
0.00
Over/Under
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve tc• 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 bu lding 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
Certificate of Occupancy
` Building & Safety Department
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 Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 77-730 CALLE SINALOA
Use classification: SINGLE FAMILY DWELLING Building Permit No.:, 0306-301
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: ROY SCHUBERT
amt
Building Official
Address: 79-025 VIA SAN CLARA
City, ST, ZIP: LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: December 10, 2003
minim