0212-066 (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
'799449 � 0.9/30/2(
/Date ignature of Contractor
OWNER -BUILDER DECLARATIO /"
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 Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirmiunde'r 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. 1I;MPT
(This section need not be completed if the permit valuation is for $100.00 or less).
k) I certify that in the performance of the work for which this permit is issued,
I hall 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 o6section 3700 of the Labor
J ZXA
Code, I shall forthwith comply with those provisions
rDate: !� S Applicant 'l.� . � 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.
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 authorize4epresentatives of this City to enter upon
the above-mentioned property foOnspe-ction purposes.
,Signature (Owner/Agent) - Date S '
BUILDING PERMIT PERMIT Ji
` DATE � � -•- VALUATION '. LOT TRACT
JOB SITE
ADDRESS 7"22, ISL. rno Roarm1+i
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER -� -
'PEM R. L JACOBS
PO BO 356
SCJ aIDIX 692
LA QJi7A 92253
LA Quftvv CA 92233
(760)777^9921 CWS 6613
USE OF PERMIT )r
.1 •,ta1�R1ui3 r 19 lILi Y10T' FI�CLUD ' Eti C1C ��+il4Lt 117C1L72 f:3P.A OR P.PPROXCH
PRIA71 WAY:COMPLEANCE'it WITH A�I, MAL 3Tj r9 LA 'i INC (Fi"1Ftd0
T1!it� �11J.Pi1dC1L�II? SPLPC°Dl�.i; .�i.C;'1' O�' 9�',;d {761J.S.L: � 4Sa1, E7� ry '� •-c� "�
CU a1'I: M COAIS_TRUdT1014 4,3V.00 SP
POPIC1'1lP.WrIO $,t(tS:Uv sp
c3��ItAG1'E/CAR1'/JRT 644,00 w'F
- ,C,a`8Tdv3l'd B.JG11/ S.rva4 B `:e�'6nRJ',LV1�Fr 4+da'�c et
.7'ealr�eb.�FJrG'f..dv !
_
PE. Rwr FRE RTYMMARY
CONSTRUCTION FEE. 101-000418-0'00 $1,S8444
NI.P.►N CHCCIK FEE 101-000-439-319
M- DEPOSIT 101.000.4396318 .$1,000.00
MECHAN[CAL FRE 101-•0,00-,21-000 $156.00
KLEf"TRICA.L FES `. 10I*000.4,20.000 %241,43
PL11MBING FEJT 101 ••000.419-000 V'121,75 '
STRONG iUlt7'f`I H FRF,-WID 101,-000-2,41-,000
OR JkIIING FEE �,OCO-,42,3,,OW
DEVELOPER IMPPACT SLE SB,40S.0t!
.ART 11`1 Pi1i11v'IC 131..FxEs • 1..z r11 270-00441-000
5.M7TGT c''C1i4MUCTIOXA 7FLARCHECK
$6,370.97 :.
LF;S° 7 111s •PATI? 1pit
41,000.00
a
D C) tISIt, PF -War FEES IT Now
.. ��,Y 2.2 2003... .. ,•
LA C UINTA. ..
-
CITY OF
FINANCE_ CERT
R GEiPT�
DATEBY
DA 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
_
V =6 F
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
— O - —7
Drywall - Int. Lath
2 O
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
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
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) Z
COMMENTS:
FL
Building
Arlrlrpcc
ling
"'City
1.,
Contractor
Address
u�l'�Cv
P.O. BOX 1504
7 0
Q%% / �y 78-495 CALLE TAMPICO
w�7 LA QUINTA, CALIFORNIA 92253
/S �r
Zip
f2?r'
J � �
Zip
City t4
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
0 24 -Z-, o,6-6
APPLICATION ONLY
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number
I.
egal Description Id f i 9 74, / Zkal2G- Z
--��. Project Description
S, 0,il % All .,1.9�
Lic. #
el.
CityI Zip I State
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 Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
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 thathe 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).
1; 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, Bulsness 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.)
1'1 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
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.)
i] 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
F71 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if 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 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 of this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
WHITE = BUILDING DEPARTMENT
Sq. Ft. No. No. Dw.
Size Stories , Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
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 Li
Rear Setback fr
Side Street
ck from
Side Setback
roperty L
FINAL DATE
I
PEG.
Issued by:
Dat
CITY IL
Validated by:
FINI
Validation:
YELLOW = APPLICANT PINK = FINANCE
AMOU
CERTIFICATE OF COMPLIANCE -Fs
Desert Sands Unified School District; z4��
47950 Dune Palms Road
Q BERMUDA DUNES r
Date 5/22/03 La Quinta, CA 92253 COD RANCHO MIRAGE (�
INDIAN WELLS ^r
No. 24446 (760) 771-8515 '�,^P;AQUINT y
IN1INDIO 1^
. ... VVV
O
Owner Eugene Davis Bishop Sr. (Family Trust) APN # 770-300-021.
Address 78622 Talking Rock Turn - ti Jurisdiction La Quinta
City, La Quinta Zip 92253 Permit #
Tract # Study Area
Type . Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 78622 - Talking Rock Turn 5178 - Unit 6
Unit 2 ' Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10 u
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 (spaces that do not contain facilities for Irving, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 5,178 S.F. or $11,080.92 have been paid for 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/Pacific Western Bank - Peter Jacobs Check No. 209167
Name on the check Telephone 760/799-6905•
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by S onnMcGilvrey $1.1,080.92 '1$0.00
Payment Recd . Over/Under
Signature G
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated ,
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting ,