9806-124 (SFD)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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that lam 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'd'o 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
co tractors to construct the ;project (Sec. 7044, Business &v Professionals
Code).
() I am exempt under SectionB&P.C. fo his reason
'
Date 4 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.
U) I have and will maintain workers' compensation insurance, as required by
S ction 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 TRUCK Y�r q C ` c R Policy No. 9 {� / t '�
1 t�UCK TINS f€Zf� NICT, i t+,ct",~ •YJ�t� Vc! Y�s
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thosevisions.
Date:l u r Applicant /
Warning: F (lure 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
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
PERMIT # CONTROL #
BUILDING PERMIT�;.��
.
DATE VALUATION 38x,94 50 LOT 4 TRACT TS 4 G
JOB SITE U y
ADDRESS ` 51•-305 F� 9:: i�t��.A,��.iC� .A..81'i
APN 7734W-416
OWNER _ -
CONTRACTOR / DESIGNER / ENGINEER i, -
Jf:SI SMIFL���ri3RE
j(
��,lC
(Mkr it P.;/'Bt1LDEP.WIiry+ il...t'9
�6640 POLK 841 ail}
45 701 MONWE S i STT O
`['.}-iF'1tMAL CA 92774
INDIC) CA. 92201
(760) 347_�!,V7 Cpf eft . .
USE OF PERMIT
NF0
:1x -D (1367d RI - >a)rsM}:(T 1D0ES NUf 3.NCs.W1 81.(Y-%' WAL1. S 0 12P0,0L,
PLAN C,'1.1EC K I'C;tF°41: IN OF 17FJ!,S tEOUCFD 75%l' * MULTIPIX ISSUANC
0F SAW PLAN TYP&
TRACT C rNX("l�UC tii'i 1,302.00 3F
IK3ttGI- PAT10 00.110 ti l'
CJXkA(IEJCAJR K )K1' 5170) 8F
ESTIA4A3I.SJ COST tis k
CONSTR 7C' It3.N FEE 101-00P0419.00I.1 �5f33.rh1
PLAN d141?CK FFT $1 IS, :1
�•tLr.;°11A:t1id'�;ll, .C'Is3 ((it-ti0t�-4�, f �.t�7t} �it�. �v
i3iI(:^IYZ[OAL l�r,.iVi 101-000-420-000
I" L A481'NO FEE 101-000-419-000 S 1 y k. Sit
I.;'r}rC NO MOTKIN APSM 101-G1M-241-0(h)
C;Rikl:r.(NO 1•'W 101-000-723 V20,00
11-NI"K rS'f.RUC'°r! UM -1. 11TAt; -225-000-443-3142 1,13.tB. L
PRF.CT,%' PLA1N
SUB•-` 0TAL CC)MI'ftIJMON AND PLAN !,';HECK
hs
LESS PRE-RcAlU FLIES
Pe (m
TOT M. DOE .1VtW
$.2,11;44•.6.1;
RECEIPT
DATE r/
����
BY
fit
DATE FINALED
INSPECTOR
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1 d% J �•
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
V
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck�+
Exhaust Fans
O.K to Wrap
_
_6
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Linen
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
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
- 2
Encapsulation
Gas Piping
Gas Test
S
Appliances
Final
COMMENTS: .
s
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 yJ _
12114 Notice (Perm)
j Desert Sands Unified School District '
: 47-950 Dune Palms'Road
." . Notice: • '
L_ a Quinta, CA 92253
Document Cannot Be Duplicated760-771-8515
CERTIFICATE OF COMPLIANCE �.
Date. 6/29/98 APN # 773'083-016
No. 17242 Jurisdiction 'La Quinta y
Owner NameCoachella Valley, Housing Coalition Permit #
No. 51-305Street, Avenida Vallejo " iog #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 1,302 i
Type of Development • Single Family Residence No. of Units 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 mobilehomes.
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
_ 1.93 X .1,302 or $ 2,512.86 the property listed above•and that building,.,;
permits and/or Certificates of Occupancy for this square footage in this proposed project m4y.iidNv 15 3 issued`'
�r
Fees Paid By Cashier Check/B of A/David Brudvik . Tel phone 3 ^ 7 3`- 7 -j �- %
Name on the check
i F
By Dr. Doris Wilson
r, Superintendent
t a Fee collected /exempted by Juanita Green Payment Received $2,512.86
?t°< Check No. 2009915354
Signature
[NOTICE:, Pursuant of A mbly Bill 3061 (CHAP 549, STATS. 1996) this will serve to not fy you that the 90<lay approval period in which you may protest the fees or other payment idenled
t bove will begin to run f the date on which the building or installation permit for this project is sssued or on which they are paid to the Dislrict(s) or to another public entity authorized to
ollect them on the Dist ct('s)(s') behalf, whichever is earlier.
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
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