9912-111 (CCOM)LICENSED CONTRACTOR DECLARATION
U) ,rT I ;breby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
o w In 478689 B 02/29/20(
oZ ti Date Signature of Contractor
O�
r-1.— 0 OWNER -BUILDER DECLARATION
HWa f` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z ( ) 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).
C1 () I amexempt under Section '' B&P.C. for this reason
N
Date Signature of Owner
O0)
a Z WORKER'S COMPENSATION DECLARATION .
o1 hereby affirm under penalty of perjury one of the following. declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL' compensation; as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q L) ( ) I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
a rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
oo :5 GOLDEN EAGLE NWC 547701400
r` O
g (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Fajlure 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
dao & hold harmless the City of La Ouinta, 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIr9912-111'
DATE VALUATION $6,350.40 LOT B TRACT 28776
JOB SITE
�2faofgq
ADDRESS 54598 SOUTHERN HILLS APN 775-120-033
OWNER CONTRACTOR/DESIGNER/ENGINEER
SOUTHERN HILLS, LLC R.C. HOBBS dba SOUTHERN HILLS, LLC
1430 E CHAPMAN AVE., Ste 100 55-960 PGA BLVD
ORANGE CA 92886 LA QUINTA CA 92253
(714)633-7260 CBL# 5487
USE OF PERMIT
COMMERCIAL
GARAGE/CARPORT
324.00 SF
ESTIMATED COST OF CONSTRUCTION
PERMIT FEE SUMMARY
PLAN CHECK FEE
101-000-439-318
$58.50
CONSTRUCTION FEE
101-000-418-000
$90.00
MECHANICAL FEE
101-000-421-000
$34.50
ELECTRICAL FEE
101-000-420-000
$39.98
PLUMBING FEE
101-000-419-000
$102.00
GRADING FEE
101=000-423-000
$20.00
STRONG MOTION FEE -COMM
100-000-241-000
$1.33
ART IN PUBLIC PLACES - COMA
701-000-255-000
$31.75
DEVELOPER IMPACT FEE
$361.91
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -PAID FEES
TOTAL PERMIT FEES DUE NOW
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
6,350.40
$739.97
$0.00
$739.97
Coachella Valley Unified School District
P.O. Box 847,. Thermal, CA 92274
(760) 399-5137_ , Ext. 235
f This Rnr Fnr District i Ise (lnly
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date: 'December 20, 1999
Owner's Name: Southern Hills, LLC Phone No. -760 564-561Z
Project Address: 54-598 Southern Mills LLC
Project Description: Comore"rcial-Building (Restroom by Poole Area
APN: 775 120 033 Tract #: of #'s:
Type of Development: Residential Commercial XXX dustrial
• Total Square Feet of Building Area: 324 Sq.Ft. ,
Certification of Applicant/Owners: iThe 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 sign on behalf of the 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
17620 k 65995 Approval
Agreement Existing
Prior to 1/1/87.
• Note:
Number of Sq.Ft. 324
Amount per Sq.Ft. s .31
Amount Collected s 100.44
Building Permit Application Completed: Yes/No
By: Foch "Tut" Pensis, Assistant Superintendent Administrative Services
Administrator in Charge
Not Subject to Fee
Requirement R
Certificate issued by: Marcela Valdez . Signature:
Facilities ClerV,
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written 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.
Rev. 09/27/99
DEVELOPER FEES PAID
AREA:
"
AMOUNT:
_ RCPT
CK N:
. CASH: -
IMTIALS:-
DATE: .
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date: 'December 20, 1999
Owner's Name: Southern Hills, LLC Phone No. -760 564-561Z
Project Address: 54-598 Southern Mills LLC
Project Description: Comore"rcial-Building (Restroom by Poole Area
APN: 775 120 033 Tract #: of #'s:
Type of Development: Residential Commercial XXX dustrial
• Total Square Feet of Building Area: 324 Sq.Ft. ,
Certification of Applicant/Owners: iThe 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 sign on behalf of the 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
17620 k 65995 Approval
Agreement Existing
Prior to 1/1/87.
• Note:
Number of Sq.Ft. 324
Amount per Sq.Ft. s .31
Amount Collected s 100.44
Building Permit Application Completed: Yes/No
By: Foch "Tut" Pensis, Assistant Superintendent Administrative Services
Administrator in Charge
Not Subject to Fee
Requirement R
Certificate issued by: Marcela Valdez . Signature:
Facilities ClerV,
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written 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.
Rev. 09/27/99
C 07A pp/.
C- Of La Q;dnta
Developers Project Approval `Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. • Contact applicant for resolution of conditions preventing or delaying approval.
Project: Common. Area Pool Building
Lot B;. Tract 28776 - Montecito Collection @ PGA West
Applicant Contact: J.R. ,Mauro @ Southern Hills - 564-5612
Application circulation ate:
Date
'Community Development Department
n
Christine Di Iorio, Plffnni
Date
Public Works Department
Steve Speer, Senior Engineer Date
-Building and Safety Department
Mark Harold, Building and.Safety Department Manager Date
Health Department-
:. Date
Fire Department
Date
• Schools•Fees Paid
Date
Al