9705-101 (SFD)LICENSED CONTRACTOR DECLARATION
I h�'e%y 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 # `"Lich Class Exp. Date
506667 8 3131tY.19.
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:
( ) 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). 1 I.V
() I am exempt under Section B&P.C. for this reason.
Date I 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.
EVAMITION ON FILE
(This section need not'be completed if the permit valuation is for$100.00 or less).
X),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
supject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
abate: 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 upori 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
permit, or cessation of work for 180 this 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 thebuilding
copstruction, and hereby authorize representatives of this City to enter •upon
We above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
(G=
BUILDING RPERMIT# ? CONTROL#
BUI MIT PE
- ,R 9705440 5163
DATE ' VALUATION $92, 49.7 LOT, 10 / TRACT 1:i1e9�r%2����
qi'%
-J ADDRESS _JOB SITE 22-S.A f'VIDAVALLEJO
APN 773-062-021
OWNER _
CONTRACTOR/DESIGNER/ENGINEER
JACK & SUZA3,14NM W C1..A P €:. At..
.1;1`.034, C9,1.1iEd.K. GXD97RAL (':t7NT:t11G MA R
LA QUI.K.1 A. CA 92253
1,,A o.'UlNTA • .. : CA. 922.53
.
C,7F,,Ol5C�:3S1 t. t;I3Z.T;? 11 i S .
USE OF PERMIT
; fjb - l%1eW AMD it .TURN MALL A3 Sff0%7N 014
PLAN. Pf AN c':� 6(%..1�"1:[�� k2il�T.�f3ii:1`sY �S90 I�(3f2 MCr4�'1'[47L 13.I:�s:;YJ}� O),
ISAI 4.E, PLAN.
`I It.A.C`�'1' �v 'S`i'i�i'%"1'Ie"1s�4• i,�47$.tj(l .�": i
!'AC7Rt•::EtlYei`I'TU �?.13U SF
t' fAk:A(4F1QARPt7.R1' 448.00 SF
BLOCK WALT, 216.1"
6 kT, WOOD k iiNai 200.00 LF
ESTINVUED
92.14%70
C01981'#%t:.tC:'i'-ICYN FEM 101-(IW419-{)O(i S6080)
•'.. _ a
PLAN C;'ial?(XI FIT13 101-000-439-3111 SIV.43
F0 Mi'O51,1, -$250.00
;v1kUCETANiG.A1, r- €:S . . I.Oi-f}fl1i-Q21-i)00 S47.00
1z'A.'C' RICAL FKF IOi1 OWI.4204M
TaLWMBINO FTT,
C
r TONG 414C7'i ION FEF RrR81D 101-000-2 41••000 S�.a,4
� - C
t .4tAlaTi�fi3 #' K lu i G 4-i101't-�i2 _000 520,00
� c�
tNFiEZAyIRt;1CTii.REk M. 22-"00-44-1-2142 da. $7;003.31
P#$l:�;iii!*f4:hi 101(4d► X41.-345 $5,tlf)
>'
Q
SUB-T(Y1,7AL t.CJN67, ?.LiCt'ION AND PLAN CfTFCK
LE,"S PIZE-NUDHMS
V.M)
TOTAL PERMIT FUES DUE NOW
S.2,842.89
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
f
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 7
F.A.U.
Framing
Compressor
InsulationVents
Fireplace P.L. 44KGrills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL P RPvA-VALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
Final .
Utility Notice (Gas) 4104 1/
ELECTRICAL P ROVALS
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)
01
`� '�,(ti'•�Yr���,"�^t Id" Y •� � fey e, i..�.X��C ~H�� `� �,3 :.1�t y--'+,�:�.-'�-�'•:���'� •a"""So'W'`• ...,..,.`_.F.�,�i ._ ,.. �v=ir--= it tir "�fL1.�'v�. }�'j.� ..
P.O. BOX 1504APPLICATION ONLY
Building _ + r 78-495 CALLE TAMPICO
Address VAL.L4 1n LA QUINTA, CALIFORNIA 92253
Mailing ^
Address 1;& it G la�l � • � � ✓r e ✓
City Zip Tel.
Contractor
Address
State Lic./ ��, ) City
& Classif. �GVV�%J/ Lic. H
Arch., Engr.,
Designer
Address Tel.
City IZip IState
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
70D0) of•Divisionnn 3 of the Business and Professions Code- and my license is in f II force and
effect 0, LJ,. 1.,.,.r� �rW c.f- i> C".¢� � �% 0117
SIGNATURE+! •� r / 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 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, 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. IL 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'I 1, 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
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if 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 sub'ect to the Workers',Compensation
Laws of lilofnia. LIP, / J//
Date 1 wner /t./� /(4 KGS`
NOTICE O' PPLICANT: If, aV making this Ce�ficate 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
1 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 1 have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
,signature of aQplicant Date
Mailing Address
City, State, Zip
NG: TYPE'CONST. OCC. GRP.
A.P. Number -773 - i' h l — l0 2-11
Legal Description r,4 1 r1' oAt- J6
Lc7T f0 Fes- 72 UGIT
Project Description
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. 250. ®�
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances: R
Front Setback from Center Line
Rear Setback from Rear Prop. Line ;
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECT
Issued by: Date ermlt
LF
Validated by: �V#tE6/ 071997
Validation:
Cin' OF LA. 0!11J11T.4a nY
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
Notice: 82-879. Highway, 111
Document Cannot Be Duplicated -Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 5/23/97 APN # ` , 773-062-021.
No. 15569 Jurisdiction La Qulnta
Owner Name Jack Clark Permit #
No, 51225 Street' Avenida Vallejo Log #
City La Quinta zip 92253 Study Area 113 `.
Tract # Lot # Square Footage . '1478
Type of Development Single Family' Residence' No.'ofUnits 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 mobilehorimes.
It has been determined the above-named owner is exempt from paying school fees at this time due to the following
reason: ,
EXEMPTION NOT APPLICABLE
This'certifies that school facility fees imposed pursuant to Government. Code 53080 in the amount of
1.84 X 1,478 or $ 2,719.52 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 B cc/Valle Independent Bank/Jack Clark " + f564 -3511 --
Name
` --
Y Y P Telephone' 564-3511
Name on the check
r
By Dr. Doris Wilson r ..
Superintendent e
Fee collected /exempted by Pauline Pearson Payment Received $2,'719.' 2'f -
Check No. 141407
Signature
Qukl A&�
NOTICE: Pursuant of Assembly 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 from the 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 Districl('s)(s') behalf, whichever is earlier.
VAI
Collector: Attach a copy of county or city plan check. application form to district copy for all`waivers.
t+ Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting