0209-017 (AR)LICENSED CONTRACTOR DECLARATION
I hereb ; affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Divisiori.3 of the Business and
ProfessionalstCode, and my License is`in full fordPand eti'sct.
License # Lic. Class') _o. Exp. Date �p -
� f
o'Date Y ` 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 owner of the property, am exclusively contracting with licensed
contractors t6 construct the project (Sec. 7044, Business & Professionals
Code). i
() 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 pAr,11I~iC PI.,OyI:,11; Policy No. WLR C43.0MI111
(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 w�Q rkers' compensation prow sions of Section 3700 of the Labor
,Code, I s. al fort h comply with t • o ejrp ouisions.
Date: �� )witApplicant# i
Warning: Failureto secure Workers' Compensation coverage is unlawful and t
shall subject an employer to criminal penalties and civil fines up to $100,000,
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 ap - lication(5101
state that the above information is
correct. I agree to comply with all City, State laws relating to the building
construction, and hereby authonzedtsentatives of this City to enter ,upon
the above mentioned property for Isctlon�purposes.
Signature OwnedA ent Date �,\�}lxv
9 ( 9 )
V
YWA DING PERMIT PERMIT#
017
DATE f r� VALUATION LOT TRACT
JOB SITE <r�
ADDRESS St SL^ P R � DRIVE APN 757-5304M9,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
`tol"J,BROUBWINC
'T'0.1. LBROTI'W..R IRC,
74-92:3 HC''e EGY LANE E T ULTIZE-2420
74-:923 HOWILY 1ANY, HAW GUT112-220
Z~x: m T E=r Cis, 92260
FWLM 53:�,tMT CA 92260
(760)674-V699 CSLN 3632
USE OF PERMIT
.%'EEb"y. PAXI.ice Ai DUION
S1: PP d MKI1+l`iAL TO PFIRMIT # 0203-213 R.I;N'L TJNQ .ADL)I'TIO'N OF 30
SY, CMITA TO RESIDENCE ilAii' FA CONURUC MON
CUITYOM 4` 40TRUCTION 308,00 3F
ESTIKA� M O6yU OF OO V MMMOht
2.� .2qI
COASTRUC`IION.FEU 101.0004 ,49.000 MIN
PP.,K.H CPPIcC .lei' w; ..' ,.. iG1-UsJD �t39-�a1a3:�o0.ga
MECHANICAL 'IANICAL FM, '. 101--000-421,000
ELECTKICItLPER, IU?-t)Ot1-42�A�tiiatS 6fi."1Ii
PlIumermo FEE 101 -OM 19.000 530.04
t'M0101VOTION PER - RE.031D 101-000-241-000 00-241-000 $2.40
U-433 PRE -PAW Fh
$0.00
W PERMIT FET I'll, DUE NOW
�
"V&s 5.12
2002
f 0C1 3 r
CIN of QUJtATW
RECEIPT r I:BY- (L
DATE FINALED
INSPECTOR
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
0. 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
erior Lath
Drywall - Int. Lath
•�
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
7 r Piping
Heater Final
Plumbing Final
�_; g Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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
Utility Notice (Perm)
COMMENTS:
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 398-5909 — Fax (760) 398-1224
This Box For District Use Only
DEVELOPER FEES PAID
AREA:
AMOUNT
LEVEL ONE AMOUNT:
LEVEL TWO AMOUNT:
MITIGATION AMOUNT:
COMM/IND. AMOUNT:
DATE:
RECEIPT:
CHECK N:
INITIALS:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date: Pctpber 30 2002
Owner's Name: Toll Brothers. Ind_ Phone No. 777-1565
Project Address: 81-650 Tiburon Drive (308 Sq/Ft) 81-065 Kingston Heath (317 Sq.Ft.)
Project Description: Addilti.6 iitt) +House Under Construction (two)
APN: 767 530 009 Tract #: 29348-2 Lot #'s: 12
767 490 001 29348-1 1
Type of Development: Residential XX Commercial Industrial
Total Square Feet of Building Area: 308 + 317 = 625 Sq.Ft.
Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement
under penalty of perjury and further represents that he/she is authorized to s!WA behalf o ie owner/developer.
Dated:, Signature:
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project Agreement Existing Not Subject to Fee
17620 65995 Approval Prior to 1/1/87 Requirement
r� Ti buron,.. Kingston Note:
Number of Sq.Ft. 308 317
6:mount per Sq.Ft. $ 2.416 2.16.
Amount Collected $ 665.28 684.72
Building Permit Application Completed: Yes/No
By: Carey M. Carlson
Asst. Supt., Business Serv.
= Total Received $1,350.00
Certificate issued by: Marcela Valdez Signature:
Facilities Clerk
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1Ca)�r •itten notice to
the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day period to protest the imposition of
these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the Government code and other applicable law, this Notice shall
serve to advise you that the 90 -day protest period in regard to such Fees or the validity thereof, commences with the payment of the fees or performance of
any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether
payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date hereof. This
Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School
District, and up to three (3) such extensions may be granted. At such time as this Certificate expires, if a building permit has not been issued for the project
that is the subject of this Certificate, the owner will be reimbursed all fees that were paid to obtain this Certificate of Compliance.
MV:c/mydocs/devfees/certificate of compliance 09/30/02