0306-153 (SFD)LICENSED CONTRACTOR DECLARATION
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 # LLic. Class Exp. Date
11 03/3112('
Date a! l �t Signature of Contracto;•
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.
(%p) 1 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 STA"l,l,.l) Policy No. !".011-bEi
(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.
+ Dale y. •' .!Applicant
Warning: Failure to secure WorkersP' Compensation coverage is unlawful and
shall subject an employer to criminaf'penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person'at
whose request and for whose benefit work -is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indem
& hold harmless the City of La Quinta, its officers, agents and employeeni
2. Any permit issued as a result of this. application becomes null and void
"work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter'upon
the above-mentioned property for inspection purposes. ;.
Signature (Owner/Agent) �i Date ',rt
- BUILDING PERMIT PERMIT# _
DATE VALUATION.LOT TRACT
JOB SITE-
APN
!y p�*
ADDRESS VAIJ KJO
OWNER'
CONTRACTOR / DESIGNER / EN (NEER
P.O.1"' O 1 141
513 IlJ AXENTOA TAULI 1P'>A11
CA 542,213
Cl � •i44i�4' OVA. 62u_,
USE OF PERMIT
f
p} ggry�p; 'gyp{
leLl:1i.4:R i' ILY Dti1'a%3..u.J G11
IM 3, F SK) PERMIT. O]T r'NOT MCLUDE 6LoCY. WAIZ, Pool, f ; ;
D&N EWAY.4PPROACH °i
TRACT CONSTR.Uf::T)ON ►,i��.a
POR.cm/!':uto ` A4.00 :R7
C3ARAClI.isaP.I4t'e It i 4NM t3lt
i
rviM;IY+wm con C'iil' ccrxuk`!~ o .` r CSN
CKMSTRUCTIOX ASE 101.000.41.9-wo
FEE DMOSIT 101-0 00-43.9-318
.`ltl' tMti►
t►3t'E♦��';�Z•I.f�LXIIC- t, VEi 1101
;
�1 �fv'$fA� ?:�A $11N.09 9x
I:.ieCrw il,�.9\.,,Cit+'I�I: i.• �101"tJ!•?t/'di�h4J-000 $11N. 9
'
STRO1`NO.MOTIOIH PRE s,.'.+`'A D 101.000d243 -fit) f, It, 70
tTii �.171�i�3101-
DW'ELOPER IM, PACY FM
111100
r t
61;v-D��:P} :Ayy>
�. TOTAL T�'I ��€i7': + 1�.'1N,� F ,�t? NO
JUL p'7 20031 ! m�
OF LAQuiNTA.
CITY
RECEIPT
DATE
C
By
D E FINALE
INSPECTR
r�i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Q
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
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) o
COMMENTS:
.. f
o-.
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
Q BERMUDA DUNES
Date 7/7/.03 La Quinta, CA 92253 � RANCHO MIRAGE
e INDIAN WELLS ti
No. 24670 (760) 77-1-8515 C�j PALM DESERT
t}� LA QUINTA �y
D
INIO
Q i l
Owner
Kellogg
APN #
774-213-003
Address
P O Box 1141
Jurisdiction
La Quinta i
City
La Quinta Zip 92253
Permit #
0306-153
Tract #
BLK283
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 22 54080 Avenida Vallejo 1789 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments Certs #24670 through 24672 used for CC #8370766 in the amount of 10,081.54.
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:
. i
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 1,789 S.F. or $3,828.46 have been paid for the property listed above and that ;r
building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued.
Fees Paid By CC/Union Bank of California - Marc Kellogg Check No. 8370766
Name on the check Telephone 760/880.1725
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collectec
Signature
Payment Recd
$3,828.46 Over/Under
NOTICE: Pursuant to Government Code Section 66020(d)(1), this'W* erve 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
Embossed. Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
o.Certificate
�-- o of Occupancy
ot ' /; ,
G� of & Saf Buildin
g et Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, 'at the time of issuance, this structure was . in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
Use classification: SFD
Occupancy Group R
BUILDING ADDRESS: 54-080 AVENIDA VALLEJO
Type of Construction: VN
Building Permit No0306-153
Land Use Zone: RC