9602-067 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the 'Business d4 rofessionats�Code, and my
License is in full force and effect. rpt " ;1 s
Licens # Llc: Cl1ssExp.
Date- Sign
Ab
OWNER -BUILDER DECLARATION
I hereby affirm 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 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.
(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 pr�vision of Section 3700 of the Labor
Code, 14all;forLhVj j� comply wit f' O ose'provisioi
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 tc 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 ii. performed under or pursuant to
any permit issued as a resultA this,application agrees to, & shall, indemnify
1.e r M1.i.;.r,;�+it
& hold harmless the City of Indian.Wells,416 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 repr sentatives�of this City to enter upon the
above-mentioned property for inspectio purposes.
Signature (Owner/Date ✓ r'�- -5
.i
A`cx
BUILDING PERMIT
PERMITS
9602-4167
DATE 31 6/96
VALUATION 5.163.1192 40
LOT 75 TRACT " 25389-1 .PHASEI,4P1
JOB SITE ADDRESS
APN
56i 290 SP G.1,ikSS H8i,.L iDRtV�s.
OWNER
CONTRACTOR
rA Y 1351ZS GROI N
III T01ir�f1'C'C ! (�. uAYVA
1. .I3 s\ fl, s.l'S J/ l-713'11 s,
"'!"�C'0.�C1' 1'6"�'V'1f f"l. ��
i .,1. .: t .1 �./1J ♦J/,i ,.l 1 11.
301523 i fU`kN1 i MW.i XSE
COSTA fvIl sit (ll. 212.6"2v
LA.QU-1-WA, CA. 92253
(71 [itSttli.FiflF,fl t''i�t:it t0,1
DESIGNERIENGINEER
(j;lg't' 71 K24
14? A_NK �I("?td7..A11—S & ASSOC.
i33E E -AST C1'1!#€ MAN AMR
USE OF PERMIS1,-40L) F-iV 1.1LY i)N1i3��.1,,t ING
LAc UINTAI+AIRW.AYS
FEE DESCRIPTION
FEES
CUS'IX)m CQN31'1t11(.1'10N 2,014.04) SI»
PORCH/PATIO 1,38.00 SF
CARAGIVC,A2ZP4:i'E T 484.00 SF
GI NTIF`t4`lA7l ED COST Or, CONSTRUCTION
P E:RINJJT FLZF, ; UM.liW(y
r
P.1 -AN CM`CX F'Flz. S7115.&IZ
+
C014S'1'Rlt7.l I(X4 FIT, 101-000-418-000
Il•11s1:T-.bAWLC AL BE I l.6.t-1101/-Qi_4)00 i. 0
ELF,CM.CAL FEE 101 -WO -420.000 $143.67
PL UA119][No 111 1.01000-419•-000 $145.55
ST ONES MOTION FER W RESID i01-000-241-000 S1ti. y2
CfRAU NG �TE 101-0(M 423-00 0
IN RASTRUCI'Udt.E FF`E 225-000»443-34.2 53.743.48
ART YN 4'10111C PI ACI.,Q -1"5Y) '?i)!_W0-255, $170.53
o
/ SUB-1Vf.AL CU.WWRUCTION 1AND PLAN CHECK
LESS PRE FEES
$0.00
-PAID
0
1 MqR 0 /TOTAL PERMIT FEES DUE NOW
8.1986 �
us,890.08
41
RECEIPT
DATE
BY
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
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
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
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:
.i
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
Utility Notice (Perm)
•r
CI'? -Y OF LA OUINTA
BUILDING S. SAFE'Ty OEPAF=
Notice:
Document Cannot Be Duplicated
Date 3/4/96
No. 14198
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Fairways La Quinta
No. 50280 Street Spyglass Hill Dr
City La Quinta
Tract # 25389-1
Type of Development
Comments
Lot # 75
Single Family Residence
Grandfatheredsq. ft.
APN # 769-061-005
Jurisdiction La Quinta
Permit #
Log #
Zip 82253 Study Area 125
Square Footage 1
No. of Units 1
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:
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Mitigation Agreement
in the amount of 628.00 X 1 or $ 628.00
the property listed above and that building permits and/or Certificates of OccuRancy for
this square footage in this proposed project may now be issued.
Fees Paid By La Quinta Fairways. Telephone 714-��40-6060
Name on the check
By Dolores A. Ballesteros-
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $628.00
IL Check No. 02356
Signature � aA I �2 R Q A I SAPV—
Collector:
VCollector: 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