9803-015 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N w Professionals Code, and my License is in full force and effect.
O =) co License # Lic. Class Exp. Date
I,—LLJ
�jl(? B 51:)11)9
Z r- /ate-7_;1-15�� Signature of Contractor.
CO 0 i
J U 0 OWNER -BUILDER DECLARATION
HLuLu rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
co License Law for the following reason:
Z_ ( ) 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
LO
N Date Signature of Owner
ON
0)
z
WORKER'S COMPENSATION DECLARATION
C:) Z> Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X LU LL- compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
C0 Q I have and will maintain workers' compensation insurance, as required by
O U Q Seclion 3700 of the Labor Code, for the performance of the work for which this
LL rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
cb d 24,;N1'1117/hSORA'NC311 Z(11i206121 I2
J
(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
Cpde, I shall forthwith comply with those provisions.
,pate: Applicant /t /a l r J .,`��
Warning: Failure to secure Workers' Compensation cdverage 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.
-ign ature (Owner/Agent)Dat
l.A(i`/'c " , r + {-� , e
l
/ ` t
BUILDINGPERMIT PERMIT# CONTROL#
>3,04 4t) LOT I.
VALUATION $619,048.4t)
TRACT '.0056
DATE - 7/2- le?
JOB SITEv
ADDRES 79-450 OM FZIO LANE SOUTH
APN
7611,5J4_001
OWNER
CONTRACTOR / DESIGNER
)c J [�
11117NR� i� ��URUDICK
(/ENGINEER
•i•tii.�i.t�t
'5525 MRADISE. ROAD
549-16 fiHQXL CREEK
HIDDEN HILUS (;A 91M2
LA QUINTA CA 92251
(61!='1777-761 i 03LIf 17/51
USE OF PERMIT
Sf' 13
,t
S1'1)..i'%ilfvii`i '[7tali 1 NOT INCLUDIS NOCK Wrtl.i,S OR tI%K-ti;
J
U L 0 2 1998
CUSITOM CONSTRUCTION rCTION x,5-10.00.3
NO1i.CI-1111XV10 $02,00 511
tirl#tAS.ils/E Akif'itIt't y53.ikt S11 .��Tly
, r
r�
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0+. NSTRU14-1101.4FE'r 100-ON11-41K-1;ltNt
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C'*All8Nt, I- Ill.. 101.009-4.134)00
itVFRA:i YR.11,"Pi!12EVE*t' '22:54M-4113 -.42 $h,wo.w
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S1,111 -'1'04'A,1, CON.: f'iOK,`VION ANY) t)t,AN 01I CK
$12,684 90
I'J'S8 PRET-PAID VETS
-$1,()t►t) txl
'i'ct VAI, J11K i111IT 1k FN;S jDUK NOW
$1 1,(j84.99
'1�u.r'.5 /`',_: �•Alla
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
`
Underground Ducts
Forms & Footings
Ducts
Slab Grade
- l S� lir
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
_ CI e��
F.A.U.
Framing
l
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3=z -
Drywall - Int. Lath
Final
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
- ��� (J G.
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
7 - 2 10 `p G
Pool Cover
Sewer Connection
�_ / (
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
/Q
Final
Utility Notice (Gas)
Ac ✓� ca w.��e f `7 _ 3 g
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
U u G Z
Exterior Receptacles
G.F.I.
Smoke Detectors
G
Temp. Use of Power
_
(� ,
r
Final
(Wity Notice (Perm)
IV—
y.._� 7.�;, �:�.T- �... a� wry ._. _ ti.'F�ur rti - '�•• ,r-...'r"ti..; r � �.., .. _ ._ 'i
-�r TA*4 4 Zo f�G,�i�G'
_S
i
-75 -460 I. A710 i,^( S. P.O. BOX 1504 APPLICATION ONLY
Building 78-495 CALLE TAMPICO
Address " LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address
City ('A JZip Tel.
P 11) cyj 01w_., 3'VZ
Contractor
r4l,�PI,Ll CCti.57 R urr, p'v ro.
Address
7 � f-1 (l1 L (_C: ESTE 0 #2.04
City Zip Tel. `7
`,4 r� S 777- 74/1
State Lic. City
& Classif. 7616 4/ 0 Lic. #
Arch., Engr.,
Designer "
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Businessyyand Professions Code, and my license is in full force and
effect. / /1 1, P 1 1 t /Its nt `.:� )�
SIGNATURE? 1 DATE
OWNERZILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to'its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that.he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (E500).
l'J 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
o! proving that he did not build or improve for the purpose of sale.)
('1 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
doesnot apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
F1 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of aQplicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number -169 - 434 - oo
Legal Description 6 c r / Lie— 2 -7 2-6
Project Description -5' A' C O.4, I =t 1W 'L',' '(' k , r )C-/ e
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
mated
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback fliom Rear Prop. Line
Side Street Setback from Center Line
Side Setbac6,rgm Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation: MAR 3
1998
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION Ct T 1 OF LAOu f
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Notice:
Document Cannot Be Duplicated
Date 6/30/98
No. 17255
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
` APN # 761-534-001
Jurisdiction La Quinta
Owner NameMr. Henry Burdick
No. 79-450
city La Quinta
Tract #
Street Tom Fazio Lane S.
Lot # \
Type of Development Single Family Residence
Comments
zip 92253
Permit #
Log #
Study Area
Square Footage 7,570
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 following
reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 7,570 or $ 14,610.10 the property listed above and.that tiu` ildnio� ,
as .�... ,.
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
C
Fees Paid By Cashier Check/1 st Community Bank/Mr.Turpin Tel4honez771-7511
Name on the check
By Dr. Doris Wilson �L
Superintendent
Fee collected /exempted by Juanita Green Payment Received $14,610.10
Check No. 079798
Signature (J�/� I
NOTICE: Pursuant of As #mbly 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 fr6m 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
Cor# 1 no9'S35V
-Cal West Engineering. �f
• Engineering •Architecture•Surveying• Building & Safety Services
CAUm'immark-
L toteof�Transmittal
o f L_ QDate: to 3 0 y e
De . f . Project9.703-a/S rd
o%f O.:
Tel v .Na Z�T ct No..
No.. C -= 6
Woe are forwarding: X By Messe er ' By Mail Your Pickup
• No. of Copies Descripti `' '' J.
e�1
J
;E
Comments: ' M ay k -
This Material Sent for: �.
Your Files Per Your Request
Your Review'- Approval
i = `''`Checking At the request of:
Other
Phone #`
32-812 Aurora Vista • Cathedral City, CA 92234 • (760) 328-8150
Offices: Cathedral City • Orange County •
.Bron Young • Kurt Saxon .
s x
Certificate of Occupancy
City of La Quinta -
Building and Safety Department A -f oV FmE°`s£
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 79-450 TOM FAZIO LANE SOUTH
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction
Owner of Building: HENRY BURDICK
Building Official
I
Bldg. Permit No.
VN Land Use Zone
9803-015
RL
Address: 5525 PARADISE ROAD
City: HIDDEN HILLS, CA., 91302
By: DANIEL P. CRAWFORD JR.
Date: 11 /23/99
POST IN A CONSPICUOUS PLACE