0009-083 (SFD)r
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
r �
/ / a . 0:x/:41 /V
Signature of Contractd(
.OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
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..
(y,) 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.
ZT041TH INSURANCE - • 7,.,042062403
(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:
rovisions'Date: �'= /fie Applicant �'IL%�tI-1�f1 f>ufiT t��
y i
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject,an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application -is hereby made to the Director of Building and Safety
for .a permit subject to the conditions and restrictions set forth on his
application.; o„
1. Each person upon whose behalf this application is made .& each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& .hold harmless the City of La Quinta,, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessatiori of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City. to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/AgbntjZ11Y1f/� Date
f,
BUILDING PERMIT PERMIT#
`r
DATE / /� VALUATION LOT` TRACT `
-
/ i . r?31>�/$ib .
JOB SITE
APN
ADDRESS 79420'x'{3 M 1FAZC0.LAMY, 80*fff H
.
OWNER
CONTRACTOR/DESIGNER/ENGINEER
SACK MCCIII ONXID
u"R-3 C'il`. N IRUC11014 Co.
1098 VIRM PLACE
78-120 CALT-Z E WAD0 47106
9PAN FCRD CA 943
LAQUIWrA CA 0231
(760)11- '761-q t`%3L4 3751.
USE OF PERMIT
Er NG.1- EAM{L.'Y' DW0,LZT(+
ae lblif71��3AICs1 1AIC.LtICir.L3LOCK WA1JMRt 9WAY/AP�'lrC3ACkI
CUSTOM CONSTRUCTION TION 4,M,00 OF
I'mii. sp
p09
/PyUpe[:CAi/i(�IglPATiIO }pryu q{
G A14�1'41.N�uiAR I,IRA (H) 0.169-.60
.
E?3TMIA.M C(7 3T 031' i`C'JN'KRRX."UOR
42V,61820
CONSTRUCT10*9FEE 101.000.415.000 s1.gwI.oa
PI.,P,Al CHFCiC. RE 101.1000,439-318 $4441.63
FEET DEPOSIT 101-000X39-318. -SI:,000 to
MI?'miAmICA L.. PrE 100 -000-421-000 $162.50
T;IAc TRICA], HE 1014,ft-410-000 $20.32
PLUMB1140 FKZ 421150
T it�AfKt MOTION FEE- PCF,I9I1} :1s31.00i?-241(-000
C1R:ArDrH0 P'ZE $110.00
E}E'IJ;k.I OPEt1. IMPACT Frig
,ART 114 PUBLIC PLACES 0 RFS1001-000-253-000 $571.53
t!
3C.1R/-1'+' TAI, CON'£f I U'C"flt. N Alii) PS..Ali! C:'HiY0C
$6,418.38
12.30 PRETPArG1k FW- 3
-5S1,000, 00
TO'N'AL 1MRWT Fn'o3r DUE NOW
DEC 0 5 2000
.017'Y LAQU041
RECEIPT
DATE ��?�
By /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OOERATION
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
O.K. to Wrap
!
F.A.U.
Framing
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
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Mt ZA I„
Equipment Location
--=p
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
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 (Perm)
i -
f q
ITY OF lUINTA
cF� BUILDING & SAFETY DEPARTMENT
+
OF 777-7012
164 : ECTION REQUEST LINE
777-7153
Owner 4&K MCCDONALD
Cont or_lugPIN CONSTRUCTION
Permit Number
0009-083
POST ON JOB. IN CONSPICUOUS PLACE
f. INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRES:i 79-420 TOM FAZ_IO LANE
l SOUTH
SFD-DOES NOT INCLUDE BLOCK
TYPE OF INSPECTION I DATE I IIMSP.
MAIN GROUND �aYSTEM
GROUND PLUMFlN_G
PRE-GUNITE
DO NOT POUR wnu�`�'�e-- _
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNS
ROUGH ELECTRI.3
ROUGH PLUMBING
ROOF
BOND BEAM
O.K. TO WRAP
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR 1 -
EXTERIOR LATH�—
j POOL FENCE & GATE
SEWER SEPTIC TANK
i w
FINALS
ELECTRICAL /
FINAL GAS TEST _
HEATING -'MC
HOUSE NUMBERS
TEMP POWER
Notice:
Document Cannot.Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
-760-771-8515
i
CERTIFICATE OF COMPLIANCE
Date '12/4/00' APN # 761-534-020
No. 21275 Jurisdiction La Quinta
Owner NameJack McDonald Permit #
No. 79-420 Street Tom Fazio Lane South Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 4993
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 4,993 , or $ 10,235.65 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 CC/First Community Bank - Bill Turpin Telephone 777=7611
Name on the check
By Dr. Doris Wilson
Superintendent �, t •`
Fee collected /exempted by Ellen Patino Payment Received $1(Y,23.5.65
0, Check No. 097968
Signature
OTICE: 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
bove 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. Distdct('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
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE RUCT. STEEL ASSEMBLY ❑
❑ POST TENSIONED CONCRETE 6ASPHALT OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING W
JOB LOCATION v7q- 0t, `.� so, L o
lJ Iv t� ���+�.�
REPORT SEOUENCE NO.
TYPE OF S RU T E C Lb_b6� o/�(.J�
PERMIT NO.
D!g x
DAY OF WEEK
MATERIAL DESCRIPTION /� �� , F)�"T
Q1µ, `-'
ARCHITECT
INSPECOT`9Y
t
HRS. CHARGED
�
ENGINEER
ASSISTANTS
HRS. CHARGED
L SUB
DATE
INSPECTION GENECONTRACTOR v P CONTRACTORSk
0 LAS ��12.t,� r a - S -S —
C– -;FA 6 LCATUO t,1 a c —
0 Z)
It,, v# - Cc LS C
-4 o' 6
COPY SENT TO CLIENT ❑
CONTI U ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
I NA URE F REGISTE INSPECT
DATE OF REP RT REGISTER NUMBER
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