9806-105 (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
7{)6111.0 !'; Si311+);►
YDatey�� /t Signature of Contrac`o�:'
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).
( ) I am exempt under Section B&P.C. for this reason
Date Sianature 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
Sec) tion 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.
WN.111'1�1.11t",URIANIIM 2'a:3d'w j<:„.ax3
(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 fog 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: 4 Applicants
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 ar 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)' /�1r.tiaI Datel' 7 /f7 t
BUILDINGPERMIT PERMIT# CONTROL#
98(W -10S7
. /.,
DATE VALUATION S�,2-%,'�►� 80 LOT TRACT -.712-63
6 3
ADDRESS 79450',�OM FiV,10Iit NF SOU-C�� JOB SITE
APN 761-535.01
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DOUG 4% E1:LEN R'1;1'1 NIAN
',Tl)r1.PIN C0N:,1`lWfj f10N (-T).
3727 Sf:RRA KID
79-120 t_tiUX E -Sr 00 R06
MAMBO CA 902.65
LA QUIN'1'A. CA 92253
{
('�ti{1�7 v7-7Cil 1' CRU” 3751
USE OF PERMIT I
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AUG 0 7 1998
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S'tItONG:3tiIOT14.if.4€'1,33-RE-*'U) 101-000-241-0017 152.76
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'f0l'A1, PERMIT, N Fa�'.t; .S. 1YE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
F OPERATION I
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -
Underground Ducts
Forms & Footings
Ducts
Slab Grade �G
Return Air
Steel
Combustion Air
Roof Deck L
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
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 -
Neater 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 p
Appliances
Final
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
llltldy Notice (Perm)
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INSPECTION RECORD
OPERATION
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
I Compressor
Insulation
I Vents
Fireplace P.L.
J 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
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
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) Z`—
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)
Building
Address % r1-'7
/,4,z T4`v1 4 4 "
P.O. BOX 1504
78-495 CALLE TAMPICO
I u Pw"I r., I .1. �,9 LA QUINTA, CALIFORNIA 92253
Mailing — 1 -
Address I
:3-7-1-741�2t1-
City_ 'Zip ITel.
Contractor
!,R— /? 0 CA v E`/,40C) f#Le
City Zip Tel.
14 Wvr N-rA a e�-z 777-7A,
State Lic. - City
& Classif. -7L/Pw0 Lic. #
Arch., Engr.,
Designer 11A A- 1—
Address Tel.
City Zip State
%vf. A.. LI-_ I Gs.0", Lic.#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the BUs/i /qass
and Professions Code, and my license is in full force and
effect. t �wil��. J'�,• hd .
SIGNATUREf* DATE
+! V OWNER -BUILDER 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 ($500).
l: 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
of proving that he did not build or improve for the purpose of sale.)
I 1 I, 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
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
1"] 1 am exempt under Sec. B. 8 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
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it 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 h
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 if 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 sof this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
ILDING: TYPE'CONST. OCC. GRP.
1. Number 1(41- 535-001
)al Description
ject Description 0 % 3 i' ,1A
Sq. Ft. / No. No. Dw.
Size tGu Stories / Units /
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
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: It
Front Setback from Center Line
Rear Setback fr**om Rear Prop. Line
Side Street SetbacWfrom Center Line
nSide Setback �( Propert_y Line
FINAL ATE - INSPECTOR
Issuedibihi, I 1M - D
Validated by: p - "+ t'r''
I i �
M
WHITE = FINANCE YELLOW = APPLICANT
PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 9/13/99
No. 19300 Jurisdiction
Owner NameDoug & Ellen Weitman
No. 79-750
City La Quinta
Tract #
APN # 761-535-001
La Quinta
Permit #
Street Tom Fazio Lane South Log #
Zip 92253 Study Area
Lot # Square Footage 52
Type of Development Residential Addition No. of Units
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
1.93 'X 52 or $ 100.36 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 Ed Wright Telephone 777-7611 -
Name on the check ~ '
By Dr. Doris Wilson -
Superintendent
Fee collected /exempted by Ellen Patino Payment Received $100.36
Check No. CASH
Signature
40TICE: 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
above will begin to run from the dale 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
bllect 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
(,I.Ty O'- I �►; fel pioj4TA ; I .
..; JON TANDY
-'7 REC°D
•APR37630 Medjool Ave.,
y �`�D Palm Desert, CA 92211
g► I LDlNG Office (760) 772-7192
SPECIALFax (760) 772-7193
Pager (760) 776-3338
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY ❑
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING ,
JOB LOCATIO` iom- et/o / J -Sook, L A,=Quin r��'`
L J
REPORT SEQUENCE N0.
TYPE.STaU,CTU E �-/p � �V �
I A
PER N0.
DA E
DAV OF WEEK
MATER L DEgIPJION -
ii//C�rt
ARCHITECT
[ASSISTANTS TOR ,
+`CEJ
HRS.CHARGED
ENGINEER
HRS. CHARGED
INSPECTION _. - GENERAL,•., 6� SUB
DATE CONTRACTOR {jam 1 CONTRACTOR S A,a(e GJG
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COPY SENT TO CLIEN '
CONTI ON NEXT PAGE O -----PAGE
OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
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.
SI ATURE. REGISTERED E ORS��
AT OF AEPORT REGISTER NUMBER
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