9904-210 (AR)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
.8.
Date . Signature.of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(v ) 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).`N
O k m exempt under Section , B&P.0_ for this reason
,Date - z 2 `* '/ Signature of Owner IC t .v'r,
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:
Carver Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(w) 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 provisions of Section 3700 of the Labor
Code I shall forthwith comply with those provisions.
Date: 1. ,. i . i 2APPlicant /' I tt" ( ') ti
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
I 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./
/ignature (Owner/Agent)! t� �!Tf ��,i f7 /.i f Date -1
PERMIT #
BUILDING PERMIT
"fW210
DATE E VALUATION 58.413.20 LOT TRACT
JOB SIT6
ADDRESS S4-909 SOUTHEM IMI S
APN 769-4S1-08
OWNER '
CONTRACTOR / DESIGNER / ENGINEER
R.OS>? I G & CAROl.1''(d Shy ALL
lilt{NER i'BULDER
54909 SOU 1•iERN HILLS
LA QUINTA CA 92253
CBL#
USE OF PERMIT
coNviRT Fivi me t\H:r3m m ro,a .08 a.1. bulkhrim ROOM
a
w
CUST (A-1 CDNSTR.t3i,"I`ION i09.00 Sr.
U) STIM). kITE-Z COST OF CON11111 "'f RUCTI ON
8'.4 13.20
PERMIT FER, SUMMARY
PLAN CHEC:KFFE 103-000-43SF- 18 570.20
COMMiKs`I'?►.0N PER"!,I t1!-(1Qfl�ci'f 4 (3t)t? '&ION.dt(t
h�' . C11 A'NIC;AL C1. F 1014 -000-4.21-000 ��21,5it
EL!?.C'l ZtCALrkl: 101-000-420-000
PLUIVIBIN4r FEE 10.1-WO-•4I9•W0 5210)
S'1'1tsONO MOTIONFET - WSW 10I-4100-241-0000 $.84
St jNTM_W, CONSTHY.JCPIGN ANT) PLAN CHECK
1.424032
USS PRE. -MD FEES
$0.14
TU` 7 AL 11FRM1f F'E-S OVE NOW
$24032
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 T1474,4
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
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)
COMMENTS:
+ F
41
OF - } 78-495 CALLE TAMPICO LA GIUINTA, CALIFORNIA 92.253
TELEPHONE, (760) 777-7012 'FAX (760) 777-7011
OWNER/ BUILDER, INFORMATION ' s
Dear Property Owner: F
An application fora building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
` For your protection you should be aware that as "Owner/Builder you are the responsible party \of record on such a '
-permit. Building permits are not required to be signed by property owners unless they are personally performing their
• own work. ,If your work is being performed�by someone other than yourself,' you may, protect yourself from possible
liability if that person applies for the proper permit'in his or het name.
Contractors are. required by law to be licensed and bonded by the State of California and to have a business license
from the City or County:, They are also required by law to put their license number on all permits for whichi.they
apply. ,
If you plan to do your own work;, with the exception of various trades that you plan to'subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than Your immediate family, and the work (including materials
and other costs) is $200:00 or more for. the entire project, and'such persons are: not licensed as contractors or
subcontraciors, then you may be an employer. ,
If you are an employer, you must: `register with the State and Federal Government as an employer•and you are subject
to several obligations including "State and Federal income tax withholding, federal 'social security taxes, worker's
compensation insurance, disability "insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry our these obligations, and these risks are especially serious with
respect to worker's compensation insurance. '
For more specific information about your obligations under.Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your, obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
.. . • ' ; a ,
If the structure is intended for sale, property owners who \are not. licensed contractors are allowed to perform their
work personally or•through their own employees, without'a licensed contractor or subcontractor, only under limited
conditions. t t
A frequent, practice of.unlicensed persons professing to be contractors is to secure an "Owner/Builder" building .
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing 'their own work
personally.
•Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
4 community or at 1020 N: Street, Sacramento; California 95814. "
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters., The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
—DEPT. -OF'BUILDING AND -SAFETY - ' - -- �–=� • � T
78-495 Calle Tampico r�
La Quinta, CA 92253 ` -
(760)777-7012
F 6 77-701 }. ► ,
r ER'S SIG ATURE/DATE'" '. \
PROPERTY ADDRESS '
• is � •
q7cr4 -'740
PERMIT NUMBER(s)
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C
ITY OF LA (�UINTA . . .
BUILDING & SAFETY DEPT. ;
APPROVE
FOR CONSTRUCTION
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Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 399-5137, Ext. 235
This Box For District Use Onl
DEVELOPER FEES PAID
AREA:
AMOUNT:' RCPT M
CK M CASK
IMTIALS: DATE:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date: May 4, 1999
Owner's Name: _Robert &. Carolyn Smal l Phone No. 760-771-1225
Project Address: 54-909 Southern Hills..' La Qui nta PGA
Project Description: Room Addition
APN:. 769 451 081 Tract #: Lot #'s:
Type of Development: Residential- XX Commercial Industrial
Total Square Feet of Building Area: 108: Sq.Ft.
Certification of Applicant/Owners: The 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: t� ^ •�1 �f q Signature:
t**,r,r.+r,ttr,t,r.+t+rt,tw#•••*rt•,t+►w«*.•+►r►•s,►rt,rw,►s,t,r+trtrt.**.*••*rt,►*.r►rirt,rw+t,it,►*w,r'+►,r.
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 65970 Approval
Number of Sq.Ft. 108
Amount per Sq.Ft. $ —0-
Amount Collected $ -"0
Agreement Existing Not Subject to Fee
Prior to 1/1/87 Requirement
Note: Pursuant to -AB -181 any room addtions
or enclosures .of 500 sg�vft. or less, are
exempt from' developer.°- fees
By: Foch "Tut" Pensis. Assistant Superintendent Administrative Services
Administrator in Charge
Certificate issued by: Mdreela Va-lde7 Signature: wJ
NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES AND STATEMENT OF FEES
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.
(Paqe 1 Q1 21 CF -1R
rti>< are 0i Comaliancs: Residential .
,,Oct rule n '
Meet
y 9.0
Z
Date
suwlang Permit s
Plan Check I Date
Fi"Check i Oats
Clln+ate Zona
entorcement Agency use
,mgoance Method IPacxage. Prnnt SYSIem or Computerl
;ENERAL INFORMATION
otal Conditioned Floor Area:
✓I
uilding Type:
Single Family Addition
muni -Fa Existing -Plus -Addition
:heck one or morel
North 1South /West /All Orientations
Pntauccx/n
Orientation:
(Input o ut degrees and code one.)
Floor....- ...
lumber of Dwelling Units:
0SIabRaised
Floor (circle one or both►
lour Construction Type:
Stab Edge ....
BUILDING SHELL INSULATION
:;omponent Insulation
Construction
ocal-etc.)
Assembly LocatiorvCommentsryne
R -Value
U -Value attic. to garage.
Wall..* ........... �
sT/N?
Wall ..............
nira/ /Vd-r/' O�
Roof ........:....
Root .............
Floor....- ...
Floor .............
Stab Edge ....
,_,
FENESTRATION,
Shading Devices-
Framing Type
Fenestration Area •.,
Fenestration
Exterior Overhang
Interior !,,.yno) (m«�wood/vinyl►
blind. etc.) (shadescreen• etc.)
Orientation (sf)
U -Value
(roller
Front..... ( )
Front.. (, ) _-----------
-
Left....... (` .)
Left
Lett ....... ( )
-------------
Rear..... ( )
Rear..... (. )
Right..... ( )
Right..... ( )
Skylight .......
.D
Skylight .......
, 911
THERMAL MASS
Type/Covering
Area
(st)
Thickness
((inches ' LocatiorvDescn tion kitchen, batn. etc.)
slab/emmsed. tile, etc.)
-------------
tificate of Compliance: Residential
(Page 2 of 2) CF -1 R
ProNet Me
Date
HVAC SYSTEMS
Thermostat Configuration
Type sold or oacka e
Note input nyaw c at mmpmeo hydrtinte oats under Water Heatmg Systems, except oesgn Heating Load.
Distribution
Heating Equipment
Minimum Type and Duct or
Type (turnace. heat
Efficiency Location Piping Thermostat
puma. etc.I
IAFUE/HSPF1 rductwattrc_ ate i ta.V211 In T..ww
—�_
Cooling Equipment Minimum Duct
Type (air conditioner. Efficiency Location Duct
heat puma. evao. acalino (SEER) attic. etc. t R -Value
Thermostat Configuration
Type sold or oacka e
77 v
WATER HEATING SYSTEMS
Rated Tart
Energy' External
Factor or Tarok
Water Heater Distribution Number Input (kW Capacity
Type
Recovery Standby' Insulation
Type in S stem or Stu/hr) (gallons)
Efficiency. Loss %) R -Value
Ad -
t. For small pas stars" Irated Input s 75.000 Stumm, emetrie reslatsne" and heist pump
For large pas stars" water heetem grated input 2 75.000 slum(). lest Rated
water haters. list Energy Factor.
Input Reawmy
For tnstantarte"us pas water heetere. hat Rates input anti Remay Etficiei y.
EMtowmy and Standby Loss.
SPECIAL FEATURESIREMARKS (Add extra sheets if necessary)
COMPLIANCE STATEMENT
This cendicaie of compUance hats the budding features and pertorna = speatfcabons needed to comply Math True 24. Parts t and 6, of
tfte California Cade of Regulations. and Ihe.aom nionve regulations m rnpfement them. This certificate has been signed by the
individual with overall design resconslality. When tins oemticate 01 oompllar>ce is U&MIted for a single buddir>g plan to be built in mUbple
orientations. any shading feature mm is varied is indicated cit the Special FeaturestRemarks section.
Designer or Owner (per 6usine"s a Professions code) Documentation Author
Nam.: No c
TidWFirm: TiftfFirrn: ,
Address: Address:
Teephme:
Ur- s:
(sgnaturs► (date)
Enforcement Agency
Nam":
Tile:
Ager y:
Tei"phone:
(11"l usrstamp) (aatist
_r
i