0301-184 (SFD)LICENSED CONTRACTOR DECLARATION
•Thereby 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
20CM ,133 036 V1.21il 11/301U,
,Date -? i Signature of Contractor l 1/
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).
) I am exempt under Section , B&P.C. for this reason
Date , 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.
�( ) 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 1yF. ,1,E FU11D Policy No. 1376 5
(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 provisions.
pate: ,k.:: 1 �� -,'Applicant— r'kY --A-'y
Warning: Failure to secure Workers' Co pensa Itlt on 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. f'*
1. Each person upon whose behalf this application is made & each person a'
whose request and for whose benefit work is performed under or pursuant t; D
any permit issued as a result of this applicaton agrees to, & shall, indemni
& 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 i
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
(,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 purposes.
r.
Signature (Owner/Agent) ���� Date -.
*'
BUILDING PERMIT PERMIT /l
-
'
DATE VALUATION �) ��j{`j LOT TRACT
S97,394-% 1 ` PPLK 89
JOB SITE .�� A m�� p�yA. V♦ 7� �+4,t
ADDRESS s0.Cj°�....'ij �iJ ONtYrrlbtAd1 V.rr.•noli9
APN
�7� F«?b
OWNER
CONTRACTOR/DESIGNER/EN INEER „
N 111 BM AP
T."as C.1w3axN A`p, 3R.
11,0. BOX 2V7
73-300.FIMLEMCM I ANE,
P ALU UM.A ' CA 92261
PALM DESERT CA 92261
('160)';77-9572 CTX1 7905
USE OF PERMIT
1N6�I <IiAP,3nX 19 i LIN
1604 S. k+. SPU .1oFPJAIT .1DOE' NOT INCLUDE I3;L.u3CK. WALL, P001, OR
MY MA`X",f PPROACH. 79%R -Ml CED PLAN CHECK FRE FOR MULTIPIA
PLANS SAM9 HOUSE
TRACT' 0014Ii'1 RUCTION 1,6, w,00 OF
PORCIIMA TIO i a� OO SES,,
O.AI A43E/C:.ARP0'R'f 446A SF
- d:.A'Td.XL`Y.6A32D V{JOs 'iP.6' COINISIRUC71011
97,j3N.:70
Ebowmt3C`T1Ciq irm 'I01=000.415.000 $630,50
,
PLAN CM3 CK FEE 101•C00-1139-313 $13134
3E DEPOSIT 101-000.4.39.31€1 4290.00
MECHANICAL PULP 101.000-421;-000 $$9.00
ELECTRICAL FEE 10:1 -000-42"00 $113.96
I 'i9'kAR►'s Ff': 101•-000-119-000 $12A,00
STRtll'IC3 MOVOIN ME -'REDID 101.000.241.0030 $9.74
r
MADA40 FEE 101-a00-423-000 $15.00
tDMI )PE£R IIIPAC:T FZS $2,40.60
PRECISE PLAN 101-01113.441-34.5 MUD
d0ki$M. UC _90N,A1Q1. PLMT CHRAX
$3,588.04
FEB 21 2003 Ii � 1KY_fALYEO1�MJ?=DURNOW
CITY OF LA QUINTA
FINANCE DEPT.
`
11/I
K '
RECEIPT
DATE ,•y � =
BY.
D7 FIN
�%
ECTO
INSP
J
x
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
ZY_
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
G ���
Combustion Air
Exhaust Fans
O.K. to Wrap
_
V
F.A.U.
Framing
Compressor
Insulation
=3Q- Off
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
[.C�
Final �j_ O
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
% s��l�
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors _
Temp. Use of Power
Final
Utility Notice (Perm) —�j--
x '
" tE,b
CERTIFICATE'OF COMPLIANCE µ JFsc
DesertSands Unified School•Distfict
47950 Dune' Palms Road "' :C DU °
' .Q BERMUDA NES r
Date 2/21/03 4 La Quintai CA 92253 ' C/) RANCHO MIRAGE d
•t INDIAN WELLS
No. 24165 (760) 771-8516 d'�PALMDESERT y
LA QUINTA�
A�INDIO, �^ ,
O J
'i
Owner James Belknap x APN # 773-263-006 ;t ►
Address P.O. Box 297 Jurisdiction La Quinta ` r
City Palm Desert - Zip 92261 ' Permit # 03017184 s i
Tract # BLK 83 i Study Area
Type Single' Family Residence ' No. of Units. 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 17 523_70verndadwValle�o. .1604 Unit 6
Unit 2 . t. Unit 7
Unit 3 Unit 8` ,
Unit 4 Unit 9
Unit 5 Unit 10'
Comments Certs #24163 through 24167 used for CC #305788 '
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 (spaces that'do not contain facilities'for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes.: It has been determined that 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 t ,
Education Code Section. 17620 and Government Code 65995 Et Seq. .
in the amount of $2.114X 1,604 S.F. or -$3,.432.56, have been paid for 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/La Jolla.:Bank - James Belknap Check No. •305788
Name on the check Telephone 760-902-7444
' Funding Residential
By, Dr. Dofis Wilson
Superintendent
Fee collected /exempte y Shar n McGilvrey . $3,432.56 $o.00 • * ' "
s Payment Recd Over/Under-
Signature
• `' n r err . ' -
NOTICE: Pursuant to Government Code Section 66020(d)(1), this _will serye to notify you that the 90 -day approval period in which you may protest the fees or
other payment identifiedabove will begin to run from the date on which the building or installation permit -for this project is issued, or from the date on which
,those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier. -
NOTICE:*This Document NOT VALID'if Duplicated
s� Embossed Original; Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
ce'm!rtficate of Occupancy 4�
City of La' Q uinta
Building and Safety Department. OFNE°`��e
This Certificate issued pursuant -to the requirements of Section 109 of the Uniform Building,Code,
certifying that, at the time of issuance, this structure was. in comp/lance with the various ordinances
of the City regulating building construction or use. For the fo%%wing:
BUILDING ADDRESS: 52=370 AVENIDA-VALLEJO
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0301-184
Occupancy Group: R-3 Type of Construction: V -N. Land Use Zone: RC
Owner of Building: JAMES BELKNAP
Ale -
Building
Official
Address:
P.O. BOX 297
City:
LA QUINTA, CA 92253
By:
KIRK KIRKLAN:D
Date:
JUNE 17, 2003
POST IN A CONSPICUOUS PLACE