04-4530 (AR)BUILDING & SAFETY DEPARTMENT
P.O. Box" 1504 (760).777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA; CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-715---
BUILDING
77-715_
BUILDING PERMIT
Application Number 04-00004530 Date 6/21/04
Property Address . . . . . . 57795 SOUTH VALLEY LN .
APN: 762-250-005- - -
Application description ADDITION - RESIDENTIAL
Property Zoning . . LOW DENSITY RESIDENTIAL
Application valuation 13528
Owner Contractor
FAMALETTE JOSEPH BRINSON DEVELOPMENT
74-885 Joni Drive #3 74885 JONI DRIVE, #3
PALM DESERT CA 92260 PALM DESERT CA 92260
WCC: STATE FUND
WC: 00235662004 01/01/05
CSLB: 796459 05/30/05
CCC: B
-------------------------- Structure Information. ------------------------=-
Construction Type TYPE V - NON RATED
Occupancy Type . . . . . . DWELLG/LODGING/LONG <=10
Other struct info CODE EDITION '2001
PATIO SQ FTG 121.00
FIRST FLOOR SQ FTG 153.00
-----------------------------------------------------------------------------
Permit BUILDING PERMIT
Additional desc
Permit. Fee . . . . 153.00 Plan Check Fee : 99.45
Issue Date Valuation 135.28
Qty Unit Charge Per Extension
- BASE FEE 45.D0
12.00 9.0000 THOU BLDG 2,001-25,000 `.108. -DO
---------------------------------------------------------- ^=.------ -------
Permit ELECT - ADD/ALT/REM,'
Additional desc Fen
~r''�
Permit Fee 20.36 Plan C -ick -2` 7�00� 5.09
Issue Date Valuat on
Qty Unit Charge Per U'�'9'tgP� Extensi.on
BASE FEE 15.00
153'.00 .0350 ELEC NEW RES - 1 OR FAMILY 5.36
'Permit MECHANICAL
Additional desc
P.O. BOX 1504 Twy� VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: Date: 46
Applicant:
Applicant's Mailing
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
0 1A
LICENSED CONTRACTOR'S DECLARATION
1 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 Lice sin f II and effect.
License Class
License No.
Date C/ Z Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' 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 h e an will maintain we ers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
e ! v" ensation insurance cam p lic e r
Cartier Policy Number
I certify that, in the performance of the work for which this permit is issued, I shall n t employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree t, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forth 'h comply with those provisions
Date v Applicant aa
i
WAR ING: AILURE TO SECURE WO ERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 ct. I agree t ply with all city and county ordinances and state laws relating io building
construction an701V
ebbyauthorize representatives of this county to enter the above m ed property pection purposes.
Datev t� Signature (Applicant or Agent):
Page 2
Application Number
04-00004530.
Date 6/2-1/04
Permit Fee
26.00 Plan Check Fee
4.88
Issue Date
Valuation . .
. . 0
Qty Unit Charge
Per �.
Extension
BASE FEE
15.00
1.00 4.5000
EA MECH VENT'INST/ DUCT ALT
4.50
1.00 6.5000
EA MECH EXHAUST HOOD
6.50
----------------------------------------------------------------------------
Permit
PLUMBING
Additional desc
Permit Fee . . .
_ 45.00 Plan Check Fee
11.25
Issue Date . . . .
-Valuation . .
. . 0
Qty Unit Charge
Per
Extension
BASE FEE
15.,00
4.00 6.0000
EA PLB FIXTURE
24.00
1.00 3.0000
EA PLB WATER INST/ALT/REP
3.100.
1.00 3.0000
---------------------_-------------------------------------------------------
EA PLB GAS PIPE 1-4 OUTLETS
3.,00
Special Notes and Comments
Kitchen Remodel & Addition
(153
sqft) w/Patio Cover (121
sgft)
Other Fees . . . .
. . . . ENERGY REVIEW FEE
9.95
STRONG'MOTION (SMI) - RES 1.35
Fee summary Charged
Paid Credited
Due
Permit Fee Total
244.36 .00 .00
244.36
Plan Check Total
120.67 .00 .00
120.67
Other Fee Total
11.30 .00 .00
11.30
Grand Total
376.33 .00 .00
376.33
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 398-5909 — Fax (760) 398-1224
This Box For District Use Only «
DEVELOPER FEES PAID
AREA:
AMOUNT
LEVEL ONE AMOUNT:
LEVEL TWO AMOUNT:
MITIGATION AMOUNT:
COMM/IND. AMOUNT".
DATF.•
RF.CF.IPT•
CHECK N-
INITIAIA-
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date June 21, 2004
Owner's Name: Lewis Green Phone No. 773-4487
Project Address: 57-795 South Valley Lane La Quinta, CA
Project Description: Remodeling kitchen (small area)
APN: 762-250-005
Tract #: Lot #'s:
Type of Development: Residential xx Commercial Industrial r1
_ t
- .. Total Square Feet of Building Area: 153 sq. ft. 1
f
Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement
under penalty of perjury and further represents that he/she is author' o sign on bbl of the owner/developer.
Dated: June 21, 2004
Signature:
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project Agreement Existing Not Subject to Fee
Number of Sq.Ft.
Amount per Sq.Ft.
153
0'
Note:
E
Amount Collected $ 0
Building Permit Application Completed: Yes/No
By: Carey M. Carlson, Asst. Supt., Business Services
Certificate issued by: • Elvira Mattson, Office Technician Signature: OZC2 [ t
NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES AND STATEMENT OF FEES
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written notice to,
the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day period to protest the imposition :)f
these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the Government code and other applicable law, this Notice shall
serve to advise you that the 90 -day protest period in regard to such Fees or the validity thereof, commences with the payment of the fees or performance of
any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether
payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date hereof. This
Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School
District, and up to three (3) such extensions may be granted. At such time as this Certificate expires, if a building permit has not been issued for the project
that is the subject of this Certificate, the owner will be reimbursed all fees that were paid to obtain this Certificate of Compliance.
MV:c/mydocs/devfees/certificate of compliance form tables.doc 1/16/03 T
r , TANDY'S
INSPECTION INC.
PO BOX 13766
PALM DESERT, CA 92255
SPECIAL INSPECTION DAILY REPORT OFFICE/FAX 909.769.9717
PAGER 760.776.3339
TYPE OF INSPECTION PERFORMED[i)—ATE
SAMPLE INFORMATION
SUPPLIER
tQpd9C
TIME SAMPLE
MIX NUMBER SAMPLED AIR TEMP I
TEMP
PHYSICAL ADDRESS
PERMIT NUMBER
JOB NAM�
fAc q AIDS. LE
OF STRUCTURE
b�Z I�
ARCHITECT
ENGINEER
GENERAL CONTRACTOR
SUB CONTRACTOR
Nom' �t
WELDING INFORMATION
I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK
UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLICABLE
BUILDING LAWS.
CC:
I CTORS SIGNATURE
INS P CTORS CERTIFCA ION AGENCY AND NUMBER
SAMPLE INFORMATION
SUPPLIER
TICKET NUMBER
TIME SAMPLE
MIX NUMBER SAMPLED AIR TEMP I
TEMP
SLUMP
TIME IN MIXER
LOCATION
WELDING INFORMATION
PROCESS
WELDERS NAME
CERTIFYING AGENCY AND CERTIFICATION NUMBER ' -
I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK
UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLICABLE
BUILDING LAWS.
CC:
I CTORS SIGNATURE
INS P CTORS CERTIFCA ION AGENCY AND NUMBER