0202-115 (SFD)1. '!51x ,LENSED CONTRACTOR DECLARATION r n•
.;
1=hereby*affirm under penaltjrof`perjury that] 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
'� rs
_ Signature of Contract�� A'" '
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following. reason: 1
( ) I, as ownertof 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). ;
O I am exempt'under Section B&P.C. for this reason
Date Signature of Owner
o!
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.
(�f' I have and will maintain workers' compensation insurance, as required by
Sectlon 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:
CarrierSTJ�i'E. 0AD Policy No. 046.01.00042€
(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,
J 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' compensatiop provisions of Section 370 of the Labor
Code, l shall -forth comply w th th'ose provW ns. ! .
A— APPlican
•r
• Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject.an employes 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.
4"
IMPORTANi.Application is hereby made to the Director of Building and Safety `
for a 'permit subject to 'the conditions and restrictions set forthon 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, & sti`all, 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 suc
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 i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property/for inspection",purpos s.
/signature (Owner/AgentD�f _ � `,-- D'♦
PERMIT# `--- --,
-.BUILDING PERMIT
DATE/ VALUATION•' LOT4 TRACT.ryyl
� {r yam&
JOB SITE/
APN f
ADDRESS , !a Y66: Iwi, maLEJO
7 -1.5 -1)1(1 Y..
OWNER.
CONTRACTOR / DESIGNER
aYYi l"d'+.CV� dL!(�IY►7
y/�ErrN61NNEEEjR.�
.: .Sl�l:rd't.L.G .LfSt f241.S,�Jw�! LIaatA�. :...,j
: 3 860 CHICAGO :�s,'VY•. 'M=0.4
,RIVEASIDE CA 925.r)
mmiat CA 92508
61 5
USE OF PERMIT
y� �y ��y
r.,mml DING- IlLV�.Y'
Ja:
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51TID • PERMIT DOES NOT ;fh'CiX.D9 8LOC K WALL, POOL OR ORMT74TAY
,� r,
APP�.O.Ari,.'�.e 98 OOO�.,
TRACT CONSTRUCTION 1,503,00 SP
ii•ORCHIPA IO 961001157
C3.fRA:CiWCA.lit• O RT
.
5 ?T1 WOOD met 13a,iDff A,t'"
ESMVIA1XV CM.' Q;tCANS ULMOV
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0�5 11(520
111049-T
14Ly11=1 piY6TB
COMTRUC`TION ME 101.0004418-WJ WISP
PL-tlN CHWK FEE 1.G1-000-439-339
RE MrPOSIT 101.000-425- 318 425D,0{t
301-iVO-421-0 O
€�1.�?CT"Ii 1C.e`ri�F�+'• l tbl �J't�A%bt«�^CY(3t1 �l i�.73
PI,UnWiNG n,Iv 101 -000 -415i -WO S P Iai.�r
STtaOMG MOTION F.99 • R 21D 101.000 -U3 -IM
=o3LIaSaNaISL 3fi3 fi�i��423�00t1 S a.ca
DES VZUC)f 1~R 3MP'ACT FELE st,#07.00
301,0400-441-34:5 �S:>160.Da
•y.
SI.JTIT
$3,44931
� 6� PM -PAZ R11 u'
425. ,{tai
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I .7.'!✓ .? ,.1, R'THS!A:` 3! MS .E)"
P
4dwT31 `Fee
MAR 0 7 2002, '
A
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DA FI/#,/02INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings,�
_
M
If'
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
. p y
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall 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:
Ave l,'� (b,",
Building
,17L -/z D,-�
Mailing ` /
Address liko lily,
SZ
Cont
yi 44/ i Lit-)',
ty
V2 3
4
cei�
P.O. BOX 1504 j l
78-495 CALLE TAMPICO APPLICATION ONLY to
LA OUINTA, CALIFORNIA 92253
BUILDING: TYPE'CONST. S r OCC. GRP.
✓ A.P. Number_
Legal Description 1
Project Description
State Lic.' City
& Classif.
Arch., Engr., v
Designer
Address Tel.
ZipIState
Lic. q
LICENSED CONTRACTOR'S DECLARATION
I hereb/'affirm thaki I am Ilcg der provisions of Chapter 9 (comma ing wiS
th ection
&BB Ortllsion l6 s rad Proteasions Code, and my licens s in lull Ice and
e ecl.
NAT D
DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Busness and Professions Code: Any city or county which requires a
perms to
construct, alter- Improve, demohsh, or repair any structure, prior to its issuance als
requires the applicant lot such permit to file a signed statement that he is licensed pursuant too
me provisions Of the Contractor's License Law, Chapter 9 (commencing with Section 7000) o/
Division 3 of the Business and Professions Code, or that he is exempt therefrom, and Ise basis
for Ise alleged exemption. Any vrolaf-n of Section 7031.5 Dy any applicant for t permit
sub/acts the applicant to a Civil penally of not more than live hundred dollars (5500).
I ' 1, as owner of the property, Or my eployees with wages as their sole compensation, will
do the work, and the structure is not imntended Or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of properly who
Dwlas or Improves thereon and who does such work hvnself or through his own employees.
Provided mat such Improvements are not intended or offered Ior sale. ll, however, the oudding
or Improvement Is sold within one year of completion, area awneS-al". er will have he battles
of PIOwng that he did not build or Improve lot the purpose 01 sale.)
I, as owner of the property, am exclusively contracting with licensed contractors to con-
slrucl the project. (Sec 7044, Business and Professions Code: The Contractor's License law
does no, apply 10 an owner 0l Properly who builds or Improves thereon, and who contracts for
n
such protects with a conlracfor(s) hcsnsed pursuant to the Contractor's License Law.)
1 am exempt under Sec. - B. 8 P.C. for this reason
Date Z Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell -insure, or a certificate of
Worker's Compensation Insurance, or a cenified Copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
I I Copy is filed with the city. I'j Certified Copy is hereby furnished.
CERTIFIATE OF EXEMPTION FROM
WORK ERSCCOMPENSATION INSURANCE
(This section need not be completed If the permit Is lot One hundred dollars (S 100) valuation
or less.)
I cattily That-tn the penormanc I Ihp work or which Ihis r rs issued, I shall not
emplgper on in any m- -�aas to be f e orkers' Compenall ion
Laws It
I
Date canerA.
PPLICANT: d, aver making this Cendx:ate of Exemption you should become
SuDlect to the Workers' Compensation provisions of fhe Labor Code, you must torah with
Comply with such provisions Of mis permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work lot which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
ITLender's Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration It work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is Correct.
I agree to comply with all city and county ordinances and at"
le lawn relating to building
C911Jtruc1lun, and hereby aulhonle representatives •OI this Cl,y t0 enter the above-
mentioned property lot inspection purposes.
Signature Of applicant Date
Mailing Address
City, Stale, zip _
Sq. Ft.
Size
No. No. Dw.
Stories Units
New Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
•'k, I
--------------
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Comments
At the present time, the . Desert Sands 'UnifiedSchool District °does not collect fees''on garages/carports, covered,
patios/walkways; residential additions under 500 square feet, detached accessorystructures or'replacement_mobilehomes., It
has been determined the above-named owner, is exempt from paying schooffees 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
2.14 X 1,508 or $ 3,227.12 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 By CC East WEst Bank - Ed Whitson ' Telephone 909/779=6000
Name on, the check
By Dr. Doris. Wilson.
Superintendent
Fee collected y Crystal /exem ted b C Scott Pa ment Received
p ry y $3;227.12
Check No 2341213
j Signature
FNI.C,E-,., Pursuant to 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 ident fled
l 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
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/Re'ceipt Copy -,Accounting
RC DISTRICT -.PLANNING REVIEW .FORM, '.
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code.' Its purpose is to determine:
1) that the proposed house, design does not duplicate the same architectural style of any,
house within 200 -feet of the applicant, and/or 2) if there is a need for the applicant to file for
Master Design Guidelines. If the applicant does -need to file a Master Design Guideline, please
transmitted this information .to the Building an6.Safety Department as part of your correction
list. Please attach additional explanations as necessary.
APPLICANT WR Enterprises - Shevitski Construction
SITE ADDRESS 51-605 Avenida 'Vallejo
APN• ' 773. _ 131 016 CASE NO.: -2002-613
'LEGAL: LOT BLOCK UNIT S S..C.@V.L.Q.
CHECK AND APPROVED BY: Wally Nesbit DATE:
Inform the assigned Building plan checker upon your assignment to this case: The CDD
Exec6tive Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y .
N
- COMMENT/CORREC,TION
Verify legal and.APN information
Consistent with MDG on file (as
applicable
MDG filing required (5 filings since
9/3/98)
Architectural variety within 200 feet.of-
the surrounding area:
Colors
Materials
Architectural gpesi nVelaures
,7? 12r -
Date eso jt
EJ Planning Comiff
Other Requirements: '['City Council
Comm De
Initials'
Case No. �2
kxhlbit
With Condition
issloi
Dep
,
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