9806-129 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Cfiapter 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
C V.HC 1213V98
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). ,
( V) I, 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
tae / tb Signature of Owner
WORKER'S COMPENSATION DECLARATION
OWAJW V
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 p �rn stzr,1•11 crYY Policy No. i n t'
T4li,t•m ll�ti,11.,M }'�41�el1 8 AM7 ��4310'v0 96
(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 those rovisions.
vDate:A,a 4 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
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 r
the above-mentioned property forinspectionpurposes.
,,Signature (Owner/Agent)-y/' Date
BUILDING PERMIT PERMIT# CONTROL'#`f.
.v
?
ykikgtt4l� ,2�1'
DATE , VALUATION _ LOT TRACT i
-ok:6.50t rfi 2
l0 rl !S
JOB SITE
APN I
ADDRESS H-38. A�r�'. .HDA YA.l,.1(aUO
173A -020
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ROSANNA SiaMIL1AN
OWNER.I BUILDER � rl-11 CVHC
PO BOX 393
.437()1 MONROE ST STT G
CO.F�C�HELLA CA9!236
ME111'O C,0. 92201
'7608117-3157 C L
USE OF PERMIT
SRD
SPD (13020L) - l�.is�iliAT 1DOPS 140T.I'�S'"CLU1D1" BLOCK WALLS OK -.P004 .
PILA'N COW -1K Pcylt'1 ION 01?,FJ,-E8 RZOI 13P 7551% FOR .V 14'1;7)': I.P.L i3 ia" 8 AT4CE
OF' SAME PLAN TYPE,
'MACT d ONSIRUCT101v 1,302,00 ,;►!+'
1?010111vpxtfo - 09_00 3F
iiAl2A k'1e�4Z1.'C31Y:i' 117,00 SI:
lliS Ei�i'I.plL1V,IRDCOSTCela�S.ONS RV4,�lSAlO
46a�wi9,?6a
PERMIT
CONS TKUC710N FE33 101-000-411 •-M
Y�,,4.N C:tv''.fx k em, 1101-0190-439-318 $ t i t% L3
Nr..Ct•1r MCAL.i °t lr 10.1.-000-4214** S10.50
i; 11C:'11UtrAL F01 $119AI
1'LUNI13.f•IVGFFF, 101-0(041940) a-lal Ci
'
V1`RZO)W I p,11Y1'1t W r1r-1V ffi*,3112 11.1 4XIO-2e41-0W
2t'�yA:�-111gDt�
unt�t�ali�A.IP;y��ty1<`(t�i:.t�
y+p� �y).tytf�
FIX 225-000-46- 42 S1Xila,72
PR.ECfSEP AN 101-fiCKi-4413 145 t�L�
8011VI)MAL COR1:STRIX-TTION .e11 D PLAN CF1 rCX
$2J04 0
LESS 1'1;.1;4>,A1D FEES
$0.00
.D.3J•+ AL PERMIT 61,.fFWS VU 9.rO
:1
RECEIPT f
DATE
BY/ f ' `[`
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
4 -(3
F.A.U.
Framing
—IV r 1> 7-
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
D II - Int. Lath
Final
<j
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
_ Q
Approval to Cover
— —��
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
/jam!
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
3
Encapsulation
Gas Piping
Gas Test
S-7
Appliances
Final
COMMENTS:
Final
Utility Notice
_ c
(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)
t_
v _G QQ ��
+. Desert Sands Unified School District
47-950 Dune Palms Road
T. Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE "
Date 6/29/98 APN # 773-083=020
No. 17247 Jurisdiction ' La Quinta
Owner NameCoachella Valley Housing Coalition Permit # .
No. 51-385 Street Avenida Vallejo' Log #
City La Quinta Zip 92253 —Study Study Area`
Tract #. Lot # Square Footage ..1,302
1
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 of $ 2,512.86 the propertylisted above and;that b 'il`irlbjy;,.l .
i rOccupancy proposed, Permits and/or Certificates of for this foota a inthis roJecissued.
Fees
Fees Paid By Cashier Check/B of A/David Brudvik Tee;l' phxone1i4-;�157�y�
01
Name
Name on the check
By Dr. Doris Wilson • ''"?t4 =� .. 'n "
ti L 41>
Superintendent
,
Fee collected /exempted by Juanita Green Payment Received $2,512.86
Check No. 20099.15354
Signature
NOTICE: Pursuant of Asse y Bill 3081 -(CHAP 549, STATS. 1998) 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 fro a dale 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
tolled them on the District('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