9908-113 (SFD)LICENSED CONTRACTOR' -DECLARATION
I hereby affirm, under penalty of perjury that I amlicensed 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
13 OV31/20
Datei�12? . .Signature of Contracto ;]�114-��;`"•'�"- '
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). r
( ) 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.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, a•s 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 ihsurarice,'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.
(This section need not.be completed if the permit valuation is for $1,06.00 or less).
() I certify that in the performance. of "the work for which this permit is issued,
,,.shall not employ any person in any manner so as •to. become subject to .the
workers' compensation laws of,Ca,ifornia, and agree that, if I should become
subject to the workers' compensation prov'isions'of Section 370Q of the Labor
Code,' I scall forthwith comply withthosg prov/-pons.
Date: c• ApplicantL- dEI-
/Warning':
.• !
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 benefitwork is performed_ uhder or -pursuant to
any permit issued as a result of this applicator 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 isnot 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. 1
Signature (Owner/Agent) ' ��f� �7 t ' D-�• L Date J11 1 .
'PERMIT#
;{ ; ` BUILDING PERMITt�...�.
V
DATE VALUATION $4141 7_11. LOT -9. TRACT< s? � 470 a
JOB SITE t
'78-571 TALKING LKING OK RN
APN �C➢�-�.�:!!-�.�8
ADDRESS
'n
OWNER
CONTRACTOR/DESIGNER/ENGINEER
' �!\-%1'•t A�,11, l,r� 4
lQ.\.nS1.V.A p:Y.`.N•
1405 'ESf tMSOP, [k
4T
E.DA4'0ND � OK '73-0031
'LA. QUIRT1"JA,, _ CA 92253
(760)M4,3511 , OSLO 1115
!
USE OF PERMIT
!:)WELIA'iud.x
rt:.s�.L•$'?t
5VD - �14.�+B�.b:�CK Wh1�LLS-C.lki.POOL 6CONWLW4M' '�•i'.M lL L RAL,,w .
' S7 FATF LAV S, i3v`CL:tTt?MO'TM 0110f1NC,}l R0.1 SE'£?CIM
wQ.) t;;LF QT1[JW.)_
0=011 011 l ONSRTJCrItii 1 r 4'roll-00 sr.
1,363.0 $41
TMIMATIfM OMT OF CONS
PP,..RMJ'ti FEF SIAC"ty ARV
C'��>itVS'3"ttE�t"t �UP�f �':�:� l:U+%•-�3(;k+3-41t�-Clt3� 57�7'�7::(N.i
+''3•tl:I•Y (°i-f�f;:'i�;, )(i1 •�i:�P.d.'�'�!,.�1�. �.y ,q1b„�;s8
"s:t3lt'? SI3 ,iQli.-Ui1-639-1-:6S,tstl,tti3.
4014W-42.1. d .f�rQ
hs#�:fir.:�'�iSt.•/�,.�bf.t•` :: - :tU6-�tN.%�d2IP� �=ttt`i.�►�
i7i;rr r�sct 1^ tiff;sin 4-Ir94”,-
. S'x'CC�,'JC: 6�vf1.3"1�d;3,tif �ti •• �1],:'�i�� ��'���R*i7�, �1 ,fro
� "�'y�
,4'i�.i.
•
139VELC.it°t?4i 3 'AQ ! t k ➢ ➢t)'1.tf��
w.. j: I.
VP16.f
;.� . �u
. S*A3 -"(AAL1Q_ SrRtr`.. 1:F+n p' L.",k!4 rtJ- CRt
"X?7�,6�./JA57
yyyryry,,`pFRES'
LESS
10//
'�'f `�'f'�R. 3' .'2' '3t;.7r' A3i; 4
$5,do'iVS7
RECEIPTDATE
BY `
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
2
)2,—
Forms & Footings
Forms
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
or -0
Exhaust Fans
O.K. to Wrap
_
• !R-9
F.A.U.
FramingZ
Insulation
Fireplace P.L.
i
�`7 `
3/17
Compressor
Vents
= Grills
Fireplace T.O.
,
Fans & Controls
Party Wall Insulation
? Condensate Lines
Party Wall Firewall
j
Exterior Lath
7--2--4- 57
Drywall - Int. Lath
% - L $ - e o VI
7
Final
Final / - 3 - d/ 577--
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
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
�_� o e, S7
Appliances
Ga3 L.we.
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole - C✓
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)
`A
F.. j`. - ., r ♦ - - - r-+.-r..'s'�,. . .v r . ti ±r, a �:ti f i e r ..v^"`�:.-"rtf; 71'.�f
Building T4 IK
Address `�� 11
Owner D>
►1 M
Mailing '
Address
City Zip
Contractor C i 4.Y,
4 im- &IN,
e _
P.O. BOX 1504
78-495 CALLE TAMPICO
j u y n LA QUINTA; CALIFORNIA 92253
APPLICATION ONLY
BUILDING: TYPE'CONST. i OCC. GRP. 1
A.P. Number I 1 {�3� .� ^f
Tel. I �� i 2A4 1) ! 2 -
Legal Description 1YP'
Project Description 4C F-)
1r. - -
--5 t :1 --Aa Aver Ca,- tfavi-zx,.
ity Tel.
�L gk1Vt+ Zip 5ga3,3 5(,L1 i s
State Lic.City
& Classif. 17 ic. If
Arch., Engr.,
Designer
Address V\1 F Tel.L�
City Zip 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 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).
I"] I, as oner 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'II'
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.)
17 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
r7 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
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 slate laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Size t 4-1 �' O Storii
No. Dw.
Units
New [110" Add ❑ Alter ❑ Repair ❑ Demolition ❑
Ll
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal. wJ
Const. d
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
R Rear Setback from RearYProp. Line
6Side Street Setback from Center Line
41e6Setback from Property Line
FINAU DATE/ 1-0 d"SX 1-1 INSPECTOR
Val
Permit
Signature of a0plicant —Date—
Mailing
ate Mailing Address Validation: ,..— r�, n1 AbA�
City, State, Zip IiiJ 1 L -r
t
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
• •Desert Satids Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 10/26/99 APN # 769-930-032 ,
No. 19513 Jurisdiction La Quinta
Owner NameDon Mathis Permit #9908-113
No. 78571 Street Talking Rock Turn Log #
City La Quinta Zip 92253 Study Area
Tract # 28470-2 Lot '# 49 Square Footage 4780
Type of Development Single Family Residence No. of Units 1
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:
t
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080, in the amounf'of
K,
1.93 X 49780 or $'9,225.40 the property listed above and tharbuilding a
permits and/or Certificates of Occupancy for this square footage in this proposed project may now fie issueda,
Fees Paid By cc/VIB/Jack Clark'Jr• Telephone f564-3511
Name on the check ,,u�•"• . r
By Dr. Doris Wilson'
Superintendent
Fee collected /exempted by Juanita Green Payment Received $9,225.40 '
^ - 202493
Check No.
Signature
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 iithe 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. -I'*
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
PUBLIC WORKS CLEARANCE LETTER _
FOR
CUSTOM HOME LOTS . -
v'
�-
_ .. • •:�.-ori;:'
Prior to issuance ^'of a building permit, you will be required to obtain clearance from the'
Public Works Department for one, or more; of the following
. 6z
� :�
1.. Verification that- rough grading is complete, and the. pad elevation~ certifications -
prepared by a. licensed -surveyor, or engineer; are on. file in .the Public Works' n ._
Department. K
2: Verification that infrastructure improvements and other' required tract improvements ti ;`
are complete, or sufficiently advanced to warrant building permit_ffi
'3. Prepare an engineered grading plan that provides for. on lot storm waterretention,r
and have it checked and approved by the Public Works Department
4-
N3
• Tract 26524 (Estancias)
• Tract 26769 (Mountain View Estates):'
A d
4. Prepare an engineered grading plan that provides for building pad grading
accordance with the existing soils report and tract grading. plan;: arid. have :it;: rf3
checked and approved by the Public Works Department.
• Tract 28034 (South Valley Estates)
• �� '�-� � � F1u4►.1U ¢facts ;�, ���'Fs'��';
44
FOR INTERNAL USE BY PUBUC WORKS DEPARTMENT
•
1
. r$7'�1�• - • ' • DATE
J
F:IPWDBMDOCMFORMS%PW CLEARANCE LERER.ss
1 .i•-� w't ,;� "p0.
' - _y -