0111-287 (AR)LICENSED CONTRACTOR DECLARATION
nI"hzreby 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
D RIC
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 ownerof 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.
FUMPT
(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 prr,.ovisions:-'- � '
!Date`"` 1- .,, i .. > Applicant—
Warning:
pplicant Warning: Failure to secure Workers' -Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000.in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT, Application is hereby made to the Director of Building and Safety
for a permit subject -to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2: Any permit issued as a result of this application becomes null and void if
Work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize. representatives of this City to enter upon
the above-mentioned property for inspection.purposes
�
/ Signature (Owner/Ageni)... ak" .^ Date -x �y
BUILDING PERMIT PERMIT# r
DATE! % VALUATION LOT �DAIa^n% TRACT
i IT131074.10
JOB SITE
ADDRESS
'18,580AVEMMA
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LA.QTTdIT.rA CA 92253
1:KQMITA CX 92253
(760)4094422 23 G7
USE OF PERMIT
REMD ', VAL AD)' ITIDN
au P3111 HOU,`% XJ3 S. F. PER APP'ROVED PLANS.
J+,L)DIVON 23$.00 OF
(:AA ACHUCARPORT 16.00 SF
143SMATED COST 01i, 4.:OL ST-R(Jx°':i'. ON
1�,e�7�l.a10
X ywbuA misum".my
PLAN CH -W% Va VMS,
CONii'I`RUCTIG14 FkZ 101 -00041$-•00iD $153.0
.
MMAXiC'AL IWE -000.4214000 S40:€0
i•10
i.6-�Doo..420-3:xD $41.73
Y'LUMB1NO levy, ' - 101,-000-419-000 $4 ,00
r S°i'D2.CbNG MOTION mo = RESID 101-00o-'"c,�t -000 $1.31
Ot1AD:D1T� pK& [ e i i 000.423 -WO SMOO
Fr LA
?*t I ZIFY f3�i A1�%� aC,t�ll i l {
.9
Fi�3«ef YarR.%
RECEIPT
DATE ' /i
BY-.,
IDA1ft
INSPECT
�2—
INSPECTION RECORD
.a1
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings�j/
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck - O
Exhaust Fans
O.K. to Wrap , O
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines J_
Heater Final
_
Water Piping v
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection �
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
,emp. Use of Power
Final
Utility Notice (Perm)
' : a Desert Sands Unified School District ' -
• 47-950 Dune Palms Road #
wLa,Quinta,,CA 92253
Document Cannot 'Be Duplicated 760-771-8515
.CERTIFICATE OF COMPLIANCE
j. J �. ` f APN#'' 770-09.1-011
Date 1/18/02' a:. ,
j No. 22845 `s M1 ` �c , Jurisdiction La Quints
Owner NameBrauckmann Inc: Permit # 0111x 287 t
•- - 1 • _ ..
i ' ';
wTuug-Stre'
i I'Og #No7$ a ,
�
City La Quints , j , y Zip 92253 Study Area
,Tract # , ,` Lot # S Square Footage ' 235 _
Type of Development New Residential Addition „ . No. of Units 1
4•
• t
At the present time,' the Desert Sands Unified School District does -not collect fees on garages/carports; covered
patios/walkways, residential additions under,500square feet; detached accessory structures or replacement mobilehomes., It
has been determined the above-named owner is exempt froni paying school fees at this time due to the following reason:'
EXEMPTION -NOT APPLICABLE e { M
This certifies that school facility; fees' imposed pursuant to Government Code 53080 in the amount of
2.05 X 235, or $'481.75 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'OC/Wells Fargo Bank - Mike Brauckmann Telephone' •760=250-5151°y
Name'on the check
By Dr. Doris .Wilson ;•r, : r; '` • t ,a�.
'Superintendent
,� .R `moi • �� . .
Fee collected /exempted by Nicola Wong Payment `Received
t CheckNo? 6737702784
Signature r ` IN +. f
f
OTICE., Pursuant to Assembly Bill 3081 (CHAP 549, STW. 1996) this will serve to notify you that the 90-d; y approval period in which you may protest the fees or other payment identified
bovebegintorun from the date on which the building or installation permit for this project is sssued or on which they are paid to the Distrid(s) or to another public entity authorized to
ollect them on the District('s)(s') behalf;`whichever is earlier. • d .
Collector: Attach a copy of county or city plan check application form to district copy for all waivers:
Embossed Originals Building Dept./Applicant Copy 'Applicant/Receipt' Copy Accounting
.� r