0305-020 (AR)LICENSED CONTRACTOR DECLARATION
I 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date 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).
O I am exempt under Section B&P.C. for.th s,reason /
Date z 4, 1�� Signature of Owner
a
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.
( ) 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).
( ) 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 those""provisions.
Date: Applicant
11
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 (Owner/Agent) • ". / �� Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
l9,tCI b 2:4995.6
JOB SITE
APN
ADDRESS 45-520 STO.N.0 3ROOK COURT
604
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
RICHARD A W ASMMMAN
OVAU.R BUl%DM
45.520 3T0 3.R(X-)K COURT
LA QT TNTA CA 92253
() - Mit
USE OF PERMIT
"M TIAL ADDITION
494SP ADDITION ANO 1'70SF PIF fRLIS 1'ERAPPROV9D PISS. 2001 .. .
CDC.,
TRACT CONSTRUCTION 4".00 9F
PORCH/PATIO 170.00 SF
r
r
X&MI AT9ED C09.T OF C:i3.IriST. U "X' ON
2�A313�.7t3
PERWr ME OrAT11 MY
PLAN CHECK M 101.000-439.318 $184.93
CONSTRUCTION PEE 101-000.418-000 $294.30
MECHANICAL FIX 1 O1 •IDOO-121 0 $48.00 .
L+ ,ECT;RICAL FJPt 101-000-420-001 $40.50
MWD1340 FSE 101-000.419.000 • S4100
STR(?ND MOTION 1 • RiS1113 101-1 0.0-241-000 #2 91
Q sums AL MRUC170u AND PICHECK CK
$603.84
D S PRE -PAID FUS
$0,00
MAY 05 2003 Ta, rumrr irs i),v L NOW
3.4
SM334
CITY OF LA AUINTA
FINANCE IDEPT.
RECEIPT
DATE /
BY
DAT IN2!D
PEC
.[T
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck A 4 DAL
Exhaust Fans
O.K to Wrap
F.A.U.
Framing i _4
Compressor
Insulation —
Vents
Fireplace P.L.
Grills Li
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final ✓
POOLS - SPAS
BLOCKWALL APPROVAL
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final a
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines s _ / - ! 0 3
Heater Final
Water Piping
Plumbing'Final
Plumbing Top Out
Equipment.Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection p S,
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final In
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)
Y
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District 14c'��o
47950 Dune
� Palms Road ¢
BERMUDA DUNES 17 --
Date
Date 5/2/03 La QUlnta CA 92253 Cn RANCHO MIRAGE Q
INDIAN WELLS 'ter
No. 24388 (760) 771-8515 �,� PALMSERT y
�INDIO
C'
Owner Richard A. Wasserman APN # 604-040-016 -
Address 45520 Stonebrook Court Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # 0305-020
Tract # 23995-6 Study Area
Type Residential Addition No. of Units 1
Lot # No. Street S.F. Lot # • No. _ Street S.F.
Unit 1 6 45_520 Ston. eb c k�Cou`it 494 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 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 or Less
EXEMPT -
This certifies that school facility fees imposed pursuant to
f
in the amount of " $0.00 X 494 • 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/Richard A. Wasserman Check No..
Name on the check ~Telephone 578-1405
Funding Exempt
By Dr. Doris Wilson
R
Superintendent
Fee collected lixerqgted by PaL'aBa:rbuzza r • $0.00
' a
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 identfied 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 - ApplicanVReceipt , Copy - Accounting