0306-269 (SFD), a i
LICENSED CONTRACTOR DECLARATION
r 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
Datewr �`�� �i . Signature of Contra r-
7
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:
1 ( ) 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 1EtJ�:�T Policy No.
(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, bsh,all.forthwith comply with thoseepr..ovlslons''-
Date: �+
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�rep""r'esentatives. of -this -City to enter upon
the above-mentioned property for i specJtlon purposes.
Signature (Owner/Agent r , "~ Date
A
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT 91W-269TRACT
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OWNER
CONTRACTOR /DESIGNER'/'EN INFER
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USE OF PERMIT
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"ONSTISIfiO7' ON PU '01,4*1-418000 $69f-00
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'.H CHE1*11K FIRE 101-000-439-319 $:)1.84
7KE DEPOSIT 101-000143:-318 5133 -.a0
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ijA :!;1�7,'HsL't� i�:17 zf, 1+3Y a00414 000
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JUN 1� 2003.. 1�
[REICEIT QUI fiY .
cin o .. -x r r
CE DEFT• 9' -
DAT FIN E
G�
INSPECTOR
�.
v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-- 1-2,
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
-
F.A.U.
Framing
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
92T
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.FJ.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
�,�dw i w•� l � F� l /z;1'�� ,�
Date 6/19/03
No. 24575
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School, District
47950 Dune Palms Road
La Quinta, CA 92253
.(760) 771-8515
Q BERMUDA DUNES O ^
04) RANCHO MIRAGE
�J INDIAN WELLS
PALM DESERT y
LA OUINTA
.•�INDIO l^
o .r
Owner Power Finance Assoc. Inc
APN #
774-213-002
Address 'P. O. Box 134
Jurisdiction
La.Quinta -
City La Quinta Zip 92253
Permit #'
0306-269
Tract # BLK 283
Study Area
Type Single Family Residence
No. of Units
1
Lot # No. Street S.F.
Lot # No.
Street - S.F.
Unit 1 23 54060 Avenida Vallejo 1918-
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4 i
Unit 9
Unit 5 .•
Unit 10
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, 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
'Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,918 . S.F. or $4,104.52 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 PC/Valley Independent Bank - Mike Brockman Check No. w287273
Name on the check Telephone 760/485.9269
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sh n Mc ' vrey $4,104.52 50.00
Payment Recd Over/Under
Signature {
NOTICE: Pursuant to Government Code Section 66020(d)(1),'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 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
a
I Embossed Original - Building Department/Applicant . Copy - Applicant/Receipt Copy - Accounting