9806-130 (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
CV I-Ic'.
P 2/1-11'3l"119
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).
y�( I am exempt under Section B&P.C.1gthis reason
ate (a Signature of Owner rL1 / WORKER'SCOMPENSATION DECLARATION���
I hereby affirm under penalty of perjury one of the following declarations:
() Lhave 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.
(y) '1 have and will maintaim.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.
VAUC'.K 1N; IAZANCE < JQ107 4370 00 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 tho e -provisions.
q ate:4 3a Applicant- 4
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;.,,,,,
the above-mentioned property.f ,r •nspection purposes. '
LSig ture (Owner/Agent)" Date
�g
BUILDINGPERMIT PERMIT# CONTROL#
NG
DATE VALUATION LOT �'�d TRACT
JOB SIT9
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER/ENGINEER
_l
t 19 1 A y $ !
+
cGU? t1BUILDER YIYiy
110 368
45701 t�,C7NR0E S'r fil'E 0
INIAO CA. 9220.
[N (No CA, 92201
(74(y) 147--i 57 Cg31.Y
USE OF PERMIT
sv o f.0 202 j ph—A i a3 i . was No 1 °. ow -Lb -LIF. uOCK WALLS OR .i>Ot'�:t,.
Pt.,AN CN.(',1VK.1 0WJ'I0N OF FIEF -i X(121�0QED 75,'i6 FOR. NJOt ''!'i IIH 113SUANCE
OF �F SA E', PLAN TYPE.
TRACT COMT12i)CrION 1,i0100 SI%
tyf?i6i:kii£•P1:Cic1 159.06 80
GARA0 JC.AftK)R r 517.00 SF
i'
ESTINMTED MIT OF VONISTRU.CTION'
82.946,50
CONST MI(MON F E 101 -OW -418-000
ft!! N C fi -M F -EI'' 10! _-OW-4:19-.31 9 $ i ,1 f3.23
MECUANXAL.FV,101-010.0-42:1-000
EL'f::G'1'MAL FM $149.41
PIXIM�i'�!�*!G FEE 101-000-419.000
SIRON0 M«`! IM FEE, - R1rS1?) 101-WO-24N)ID0 $8,24
GRADING FIRE 101-000-4231-0 $'20.00
4 NTS 1• AS`rXUQ`Nf E- stili X25-400-443-342,
PR.2$CISE2'.l.AN 1101-000-4141-34$
SUB -` (_YtAL CONN TRUr>V0N WD P AN CHECK
LESS PSI:-.PAI:L7 FEES
k0.0(I
TCi'E'AL B'CRMff, E'+'KEZS .OUE" NOW.
9�CEI
i /j� �j —?A
/J . I/f ` r{
BY j ; �'
DAT E FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
r�
Return Air
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
O.K to Wrap
- Q -
F.A.U.
Framing
5�=�¢ g
Compressor
Insulation��
7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-ear ot K-
- /3- i?
Final
5%
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
1
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
3�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
(�/� 3 57
,
ELECTRICAL APPROVAL..
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
t
Final
Utility Notice (Perm)
C�
-s` Desert Sands Unified School District
47-950 Dune Palms Road
Notice: r La Quinta; CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OYCOMPLIANCE
Date 6/29/98 APN # 773-131-021
No. 17248 ' Jurisdiction La Quinta r
Owner NameCoachella Valley Housing Coalition Permit #
No. 51-695 Street Avenida Vallejo . Log #
city La Quinta . zip 92253 Study Area
Tract # Lot # ' Square Footage 1,302
Y
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
t reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 X hlr ani x>;nt,of
1.93 X 1,302. or $ 2,512.86 the property listed abode aril that�lli,uildmg'.� Vr
. .i %.L. ii
permits and/or Certificates of Occupancy for this square footage in this proposed project may now belitsued' (�I r
Fees Paid By Cashier Check/B. of A/David Brudvik • ,TIephonoy, 347,; 3157
Name on the check
By Dr. Doris Wilson
Superintendent , W
Fee collected /exempted by Juanita Green • Payment Received $2,512.86
` Check No. 2009915354
t
Signature
NOTICE:, Pursuant of AsserAiy 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 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