9602-068 (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 d.-Rrofessionals Code, and my
License is in full force and effect. int��`
License # Lic.fC��ss Exp. Le
rDate f Signature of Contractor
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).
'( ) 1, 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 to become subject to the
workers' compensation laws of C Ifornia, and +gree that if I should become
subject to the workers' compensa on pro vision of Sectionl 3700 of the Labor
Code, I shall forthwith comply with °ose provlsio s.
,Date: Applicant
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
0.
any permit issued as a resuk/bfftl application agrees to, & shall, indemnify
& hold harmless the City of Indlaii1W J_1s iWbfficers, 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 thisapplicationand state that the above information is
correct. I agree to comply with all Git d State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property�tf
�rnspectio purposes.
IzzSignature (Owner/Ager 1Data
A"'
BUILDING
PERMIT
PERMIT
f.
DATE 316j%
VALUATION $1.941191.
LOT 81
TRACT 2.5399-1 I IJASE 1.11
JOB SITE ADDRESS
APN
�(a- tit► 1��'tsB.�xA HILL DRWE
769..643.611
OWNER
CONTRACTOR
.A'YER.S LM
i ��Ir AA •LrC T p ( �. �+"y,1
F�s.1i� i'Y A i S /...t'i. QA.ili'� A
�C4�I�ir.•Ci {t
-3,95 BRIS 6IL ST. �tjk
50-525) �iIUND `.LTi kv .RSE
C;i, grip NIEStt CA 92626
LA.QL1i1wTA CA 92.2 3
(i1All S o-tl.Anhn
DESIGNER/ENGINEER
FRANK GaONZAk.6,.r5' & ASSOC.
1336 EAST MADMAN AVE
USE of PERMI,3INGLX 3=AX11L Y' Y3 LL1NG
QKANUb, CA Y'Abbb l:-U1034U
L:A (�liThl't'A I''/1112.'11JAYS
PLANA
FEE DESCRIPTION
FEES
CUSTOM. t;ONSTRUCT3iJN 2332.00 SF
PORCIWA: €'ILS 186.00 $F
GARAGE/CARPORT 313.00 SF
UAS'1' IMA' ED COSH' OF CONSTRL.ICTIi7N
19411nml
VEJIUMIT FU SI.Til9 NIARV
PLAN C:1.1Ef, K WE S745J313
C`C)NS" ITeUCTICEN1 M4 101,M)-41.8-000 3.972.00
'1114Ar1 CAL MR 101 -CO -421 -testi S53.50
.��I' .EX7CRI[ AL f -VX 101-M)-420-000, $155,38
PJI II,191,tNQ F p% 10 1 -*09A19-000 $t 1 _10
aTONG.&IC17i.3tw►Nfl%-.'RESH:% 101 -000 -241 -OW $I3.�i2
01RADINI, FLIfi 101.000.423 -ow
!N7`1Rr1,S'1R.Ut: TURF FM 225-000.4,43-342 54,31?.cSS
ART f"44 PUBLIC PLACES RtaSM, 701-M-254-0.00 $235.45
-1"t�'t'AL CC�N�� UIr-110N 11.ND PLL N CIs�ECK
$6,706.01
O.g1
O LESS PAID MES
$0.00
MqR �`AL PERMT:> EMS SUENO��
8 19
96
�
ey
.
RECEIPT-
DATE
BY
DATE RNALED
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
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 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
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
ti
Final
�Jtility Notice (Perm)
COMMENTS:
BUILDING & SAFE TY� C)I�i:'AF"iT'MENT
777.70aa r
INSPECTION REQUEV LINE -
777.7153
Owner � l':'11 ht11'A l'�+ LA 6 :I N 1'.A
Contractor .
Permit Numt�or
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST 51"'N A!,,. APPLICABLE _SPACES
-s -S 1111.1: 1)1ZIV1'.
JOB AL)DRESS_.,...._._._.....--
SI:I_> 1,01 $l 1'1.,1 N. 4
TYPE OF INSPECTION —I'DATE INSP,
FOUNDATION & SETBACK
FOOTING—STN EL____.:_____,_
MAIN G_RO(AD SYSTEM
GRc1UND Pl•UA4pIt�G - --._...__. ' •f'.�---;.�.
PRE-GUNITE __' i_i-
DO NOT POUR CONCRETE UNTIL Al4L AOOVE HAS BEEN SIGNED
CONCRETE SLAl3�y�
JOISTS & GIRDERS
ELECTRIC"A'., GOUNC 41LUF;Y; j
��0 NO'r POUR GONC(tETE UNTIL ALL A0 VE HAS BEEN SIGNED
ROUGH _
ROUGH PLUMUING
ti ROUGH GAS & GAS TEST
HEATING 8 VEtvT-'i\-'� -
F?QOF�_.__...,
....... ....
_.
U.K. TO WRAP..._ ...__,.._ j•;:-•—;::�--� �'r
GROUT 4' J f'
' FRAMING
INSULATIC,v
PRE -HOOF j r
COVER NO WORK !Jr;TIL A,UOVE HAS BEEN SIGNED
�•>_ -,T� _._��_y__---_
Eri1 E 110' L ATM
POOL PIE PLA:` rER _ ._... _.._..._. _
POOL FENCE & (.TATE •--" M"" "' _._...___
SEWER
PLUMBING ;
FINAL GAS TESL
HEATING -.A/C
HOUSE NUMBERS•--._,_._._....._..._.;._.�,,._._..__.:.:.._.r, -- .
JOB COMPL ETE:? .,_....._......:...._._.
ABOVC APPWWALS OO NOT WCL UDE RiG!-tl'TO
iY
" UTIL!''Z`OR OCCUPY BUILDING
" Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE:
Date 3/4/96.
No. 14199
Owner Name Fairways La Quinta
APN # 769-641-011
Jurisdiction La Quinta
Permit #
No. 50400 Street Spyglass Hill Dr. Log #
City La Quinta Zip 92253 Study Area 125
Tract # 25389-1 Lot # 81 Square Footage 1
Type of Development Single Family Residence
Comments
s
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 Occupancy for
this square footage in this proposed project may now be issued.
Fees Paid By La Quinta Fairways
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by
Pauline Pearson
Telephone 714-540-6060
Payment Received $628.00
(� Check No. 02356
Signature l hk M A�
Collector: 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
r�