9806-131 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C:aaoter 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
MIC UVIN/98
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
co tractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ),I am exempt under Section , B&P.C. for this reason
Date i, a a Signature of Owner ¢942�
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.
rRUCi :INSUI ANCE.1 A2007 437000Vi
(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 • ovis ions.
Date: 5 Applicant-
--
pplicant -�—»
7-0
Warning: F ilure 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 for 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, uponM
the above-mentioned property for inspection purposes. `x
,Signature (Owner/Agent) Date-�+
PERMIT# ' ;CONTROL#
BUILDING PERMIT
DATE VALUATION LOT 99iW]11.1 TRACT `""�
`32 946.51 to 1, ,
JOB SITE ;Z; APN
ADDRESS 51,405 5 A VENIDEf. VAI UJO ! 7•'—�J �—daL �
OWNER CONTRACTOR/DESIGNER/ENGINEER —
TER :SA. DAN4fAN SATd'1ANA. OWNER! W L OTER ivrrii CilHc
4,1720 PALO V 840N S't' #3I 4570I )",IONROB r", r ",TE G
INMO CY.A 92201 INUO CA 927.01.
C B I
OF PERMIT
SM ( 13fi?MR) -'PERMIT DOES NOT INC-tW ; WLOCKWALLS O.� kioo.L.
PIAN CHECK 1-401?.'VJ.0N OI:'?!;'I E-3 REOUC,ED 75°,6 I -OR. M.U1,11P ,E M+JAivC;h
OF SA'&1E'PLAN'C5g7E-.
PORCEUPKrIO t59.00 SF
0A€ .AGMAM'O.RT 517.00 SF'
F-STINILIA .a D 4..a1FleOA' CONx7UI ^`...liOt`N
C.'UNf3'l'�ctrc"Ti4W EI?J
I OI-OUt>rrtlit-0(K)
35C.%3.�►ti
PC,aAN C4FC' FRN1121-fes
419- 1 3
S? ►'S,�3
241E011ANICALF03
340, RC)
iks`f,EC.'I'?CICA FW,
' :10 i-000-420-•000
$119.41
PLOMEINGF"€ 9,
WI -M-419.0011
101-M-0-74-140)
".29
GRA1)INh,FEE",
tI�I-U00-�t2 -0130
$F91.G'tF
1} JPK.A81'RUCrrtll?L i f3£
S-OOil-4�la�yl2
+i 8itt.3
PRMMR Fa PLAN
101-000-441-345
ISUI3-� IO AL CONSU_MUC" 1't.ON AND Lwt.,+�t` ('11IHOK, SIX" 0
LESSP122^. AID RES y�!3.130
'i'MAL 1°ERRP:ST FEES M3±.NOW I S2,8,K65
RECEIPT DATE \ BY,' J�/ DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturnAir
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
-/ 3 —?IF
Compressor
Insulation
- 6- - 71 T SIT
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q S 7
Drywall - Int. Lath
oA!,
Final
Final
3
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 I
Gas Piping
PLUMBING APPROVALS
Waste Lines ��
Gas Test
Electric Final
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) (-
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Pan is
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
_
Utility Notice (Perm)
r
Desert Sands Unified School District `
47-950 Dune Palms Road ,
Notice: La Quinta, CA 92253 r
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 6/29/98 APN # 773-131-022
No. 17249 Jurisdiction La Quinta
Owner NameCoachella Valley Housing Coalition Permit # .
' No, 51-705 Street Avenida Vallejo Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # • Square Footage 1,302
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:
r
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to.. Government Code 53080 4 m,th_erampunt of
1.93 X 1,302 or $ 2,512.86 the property listed above and that'onildmg-„` ,
permits and/or Certificates of Occupancy for this square'footage in this proposed projecinay now be,issued, {
Fees Paid By Cashier Check/B of A/David Brudvik rT [Ephone, 3'4 157
Name on the checkLit R
By 'Dr. Doris Wilson
Superintendent
Fee collected /exempted'by Juanita Green, Payment Received $2,512.86
Check No. 2009915354
Signature 1
NOTICE: Pursuant of Asse y 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 a 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.
d Embossed Original -'Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting