0103-003 (SFD)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
.V Daie Signature of Contractor F y
OWN ER -BU ILDQUDECLARATION
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 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.
STATE 1PUND 04602-01-2.2901
(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 ifJ should become
subject to the workers' compensation provisions of Section'3760 of the Labor
Code, I shall forthwith comply with those provisions.
Date: / ! Applicant
L''Warning:. Failure to secure,lNorkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties,.and civil fines up to $100,000, in .
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrict'peents
set forth�n his
application.
1. Each person upon whose behalf this application ieac
whose request and for whose benefit work is perfor er or pursuant to
any permit issued as a result of this applicaton agre sh e�rxiI
& hold harmless the City of La Quinta, its officers, andloy�es�
2. Any permit issued as a result of this application k,ecoMEs null and void if
work is not commenced within 180 days from dete of i
permit, or cessation of work for 180 days will subje t permit to cSAVb(MtL*QUlN
1 certify that I have read this application and state that EPI
correct. I agree to comply with all City, and State Iaws!relating to the building
construction, and hereby authorize. representatives�of:this City to enterwpon
the abo4e-mentioned property for inspection purposes`
)�$ignature (Owner/Agent) ✓ h' �" ► _ "'' / Date
k BUILDING PERMIT : * :PERMIT"
DATE i VALUATIONSLOT �.a�n� TRACT
n �a ww6q C �,�hCff'
14113
JOB SITE
APN
ADDRESS
77-755 (!ALFX'TX1MFCULA
774-28.5-001
OWNER
CONTRACTOR / DESIGNER / EN (NEER
a7.+AAl.6ti,d HdUI3.d.V,inF'A7.•7
HARTMM 4rV11r70.7SXUC01A0
:r Q BOX :10653
FQ Bax 1063
PALM DEAMUCC C A 92261
JPA:.ai�ScY DMW CA §2261
(760)564-2 95? 'C?BL# 402.6
USE OF PERMIT
SAD - PEfiEle��++q1,�4YiT 3p:70.1���pB'tOT thIC , UDE �3t:�'.)CK. V�1�R,Y�/ra0�DUZP.Fi OR ;
7
A' 9J9K":4h.Flh'6+;H ��i[1kV}..PrYP�,Ay,
PORC�I/& ATICt W-0.00. F
r '
4Ak'.AC3UCAR:POR.T (81r) 12,zq".00
.5 PT, WOOD FEAY&. t 300.00 LF
M.W.KrED COW OF COMMUCM011
1.48,2260)
COMSTRUCT101 FEE 101•-000-418-000 9011,00
MANC•HL+'L;i; ME $564,53
MR.131A1bOMT 101-000-439-.J18 -9250,0
MF'RMANIC.AL, ME 101-000-421-000 04;30
9IICTR.WAL ME 1131.000-420-000 SAM
TlvllMMINO MPE 101-000419-000 $1176.5D
101MONO MOTION PER . RROID 101-000-241.00 5+14,32
ORAW40 729 1411.-000.423- $Ak 00
DD%'1 d /O"19Yt;R lW�ACT FEE $1o91P�,00
'
!'1�AfrK;9S&* 'PL�itiFt' 101-000-"1-343 i 00.00
g3B.,.°i`WAL E"C3RMUCITOM .AIM 1•'L." tCTMWK
sns ,sx43
IX -23 M -PAW PM
001
4250,00
TMAJ, MR= FAMRSVIVE NOW
A
RECEIPT
DAT Ej %
BY
DAT I ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
_
8
—��-�
Underground Ducts
Ducts
Retum Air
Steel_
Combustion Air
Roof Deck
O.K. to Wrap
S f _ /c�
S=gp — of S l
Exhaust Fans
F.A.U.
Framing
Insulation
Fireplace P.L.
6=� _ p ( S7
C"—p ( ��
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall'Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final8/7
Ali
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Water Piping
/ g7
�1�f; l
Heater Final
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
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 (Perri)
3 „ )c
r
Dla3'� a ICA,
P.O. BOX 1504 APPLICATION ONLY
//�� 78-495 CALLE TAMPICO Zoo—C-
Building
Address? 7 �%b �� l CLIC %C^^Iri Fc ✓C,e,. LA QUINTA, CALIFORNIA 92253
Owner 1 l 6j,- S
4 -no 11A.. rM °,..' BUILDING: TYPE'CONST. OCC. GRP.
Mailing
Address 1,zkz�7r /0 6 9 A.P. Number 77 S(',2 R -4'-d o 1 J! 00.2—
City Zip Tel. A 3 Q � ! +
f/ALIS (�%'�
<r-� 4o7-�!o I "C�a � S-7 Legal Description //�� 1..�
Contractor Project Description Lb ors, t �, /<FS.i) t'--"CG-
.anTm�r� anis %/L[i c.! �ar7
Address
%3ox /ol 3 _
City Zip Tel.
State Lic. City
& Classif. _ 6 Lic. #"1 Sq. Ft. No. No. Dw.
D a C 4 Size ;2 a Stories Units
Arch., Engr.,
Designer 16A.IC-14 0C%_" i✓ New Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel. C../
City Zip State
Lic. If
gdENSED CONTRACTOWS DECLARATION
I hereby affirm that I tri licensed under provisl'ons of Chapter 9y(commencing with section/ �7 _ /s
7000 of Division 3 0 he Business and Profes tons Code, and m license is in full force an �/' .(�'J�
effect. �/ , _
SIGNATUREDATE '
OWNER•B ILDER DECLARATION Estimated Valuation
Ithe 6y affirm that I am exempt from the Contractor's lAcor c taw for the following
ec. 7031. S, Business antl Professions Code: Any �r(ty or county which�%puires a .7
construct, alter, improve, emolfile or gned'a ti structure, prior to'Its Issuance also./AMOUNT
e applicant for such p aro file a signed stateriient that he is licensed pursuant to PERMIT �ons of the Contract0 s License Law, Chapter a9' (commencing with Section 7000) o!
Division 3 o! the Business an Pro/,ss,,n, Code, or fA t. he is exempt fherelrQm, and the basis
!or the alleged exemption. Any violation of Sectio 7031.5 by any appficanf for a perms Plan Chk. Dep.
subjects the applicant to a q it penalty Of not more the live hundred dollars (S5,p0). Plan Chk. Bal.
I-: I, as owner of the property, or my employees with wages as their sp a compensation, will -
do the work, and tVstructure is not intend d or offered for sale. (Sec. 7044, Buisness and Const.
Professions Code,, The Contractor's Licensri aw does not apply to eh owner of property who
builds or improv thereon and who does such work himself orthroughhis own employees, Mech.
provided that ch improvements are n9i intended or offered for,,sale. If, however, the building
or improvemg t is sold within one y9ar of completion, the ow er-builder will have the burden Electrical
of proving 1 51 he did not build or imp; ve for the purpose o! sale.
III, as weer of the property, am exclusively contracting with licensed contractors'to con- Plumbing a
strut he project. (Sec. 704/, Business and Professions Code: The Contractor's License Law 1
doe not apply to an owne�oof property who builds or improves thereon, and who contracts for S.M.I.
s///yyych protects with a contraclor(s) licensed pursuant to fhetConfractor's License Law./
,/��-1 I am exempt unde iS/ec. B. & P.C�or this reason Grading
/ Driveway Enc.
Date 11 Owner Infrastructure
WORKERS' COMPENSATION DECLARATION A
2001
/'Ork'yer's
eby affirm that I have a/certificate of consent to,self-insure, or a certificate of
Compensation InsuranQ9, or a cert'&d copy thereof. (Sec. 3800, Labor,Code.).QCi�Company r 7i0 rc-Iy is filed with the uy. ❑ Certified copy is hereby furnished.
?J TOTAL)
CERTIFICATE OF EXEMPTION FROM ` REMARKS
WORKERS' COMPENSATION INSURANCE '
(This section neetl of be completed i! the pe is for one hundred dollars ($100) valuation Y
or less.) /
I certify t� in the performance o�5thgywork for which this permit is issued, I shall/not
employ any person in any man ner so as become subject to t e Workers' Compens�at'
Laws of rJ�V(for�nia: � _ % _ 1
to Poe Workers' Compensation provisions of�t'fhe Labor Ciidelyou must forthwith
with such provisions or this p§imit shall be deeme`U revoked. %
`C0 STRUCTION'LENDING AGENCY/
I hereby affirm that.,t ere is a consifuction lending agency fort/he performance of the/
work for which this per it is issued. (Sec. 3097, Civil Code.) /
Lender's Name r A
Lender's Address
This is a bu� in9 permit whin properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above informatiAn is correct.
I agree to comply with all'city�and county ordinances and state laws relatjng to building
• constructl'on, and heretiy ayorize representative yof this city to enter the above-
menti�oned property for`insp tion purposes., //'
"gnatureofapplica
Mailing Address o
City, State",.p
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:
FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Notice:
Document Cannot Be Duplicated
Date 3/26/01
No. 21806
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
owner NameLarry Hartman
No. 77-755 Street Calle Temecula
APN # 774-285-001/002
Jurisdiction La Quinta
Permit #
Log #
city La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 2296
Type of Development Single Family Residence No. of Units 1
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 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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees"imposed pursuant to Government Code 53080 in the amount of
2.05 X 2,296 or $ 4,706.80 the property listed above and that building -
permits and/or Certificates of Occupancy for this square footage in this proposed project may nUbe issLPd
s ;'
Fees Paid By CC / Valley Independent Bank- Larry Hartman Tele)rilion 766-5642957
Name on the check W ,
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow Payment Received $4,706.80
Check No. 235398
Signature
40TICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) 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
:ollect 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
RC DISTRICT — PLANNING REVIEW FORM 44
This form is to be used by CDD staff for review of single family dwellings in the R�kgwesiden 0 ,r
District, in order to determine the applicability of compatibility issues or need to require the filing &-Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as yob Oy
correction list. Please attach additional explanations as necessary..
APPLICANT Hartman Construction
SITE ADDRESS 77-755 Calle Temecula C-A,,.rej
APN 774-- 285 - 001 BIN NO.: CASE NO.:, 2001-418
LEGAL: LOT 14 - & 15 BLOCK 302 UNIT 28 S.C.@V.L.Q.
CHECKED BY: Greg Trousdell DATE: 3'
Inform the assigned Building plan checker upon your assignment to this case. The CDD Executive
Secretary maintains a log book to track applications and assign case n bers.
REQUIRED ITEM
P
Y
COMMENT/CORRECTION
Compatibility Review
Case logged and number assigned.
Verify legal and APN information
Consistent with MDG on file (as.applicableol
�u��
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
C lord.
(serials
1 _ e0,
G
Other Requirements: G`I
G8
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