9609-108 (SFD)LICENSED CONTRACTOR DECLARATION
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.,
Oy 1899
Date 6'6-- ignature of Contractor
f
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 QJU,,1,A- k`A.AI:f4.f ,rig. Policy No. w'c: k}
(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 37-00-o the Gabor
Code, I shall fofitgKitkcomply with thostprovlsiow.
Warning: Failure to secure Wprkers' Compensation coverage is.unlawfuI and
shall subject an employer to ciiminal 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 representatives of this• ity to enter upon
the above-mentioned property for inspection purp s -s/'
Signature (Owner/Agent) -- Date
01
BUILDIN"" PERMIT PERMTq °°NTR°`#
419 7
DATE lE�lf19 VALUATION A j�'�� LOT TRACT
JOB SITE -A 440 iifiibGAA'� CAMP
APN
fAEIDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
c:1It! „3112L€.,.-€ A.F.MYF,E; C:-1.�;, t�rc.
3U15 MOUNITA:IN S14A00'W9 RD
50445 MMtv IAIN bRAuOWS RD
x
.� i1N1AL1101ACA. ~3'.253
(619-1564-1949
(ol5 )5C1 -I849 C:131,P '30+2:5
USE OF PERMIT
>>1,W+ X P.A> %d N DW -1- JNO
260"QkA'31 PAi X
TKVINR CA. 92714 73.4-261_.1*49
S;i'..0-PI1f04Yf I.)OE. NOT iln ct.-65 ; flock. WALL QR !-'CiOL F' EAST :NY;Y1'I; ARM M P(m.—IC:
fit,At.l;;, f:.ltsl3i'i' fir tf3't:'ts'►'r3t,tT�.'3'r� ,4.sfitl�:llF1P.Id'i' 4V17')9. �T,A�f3•i1t�t'Y,
PORGI f1�i,9t!! SF
C3AICtlC lCfhFtk't i#Z (A6.0 Sr
`ESTIAIATEO (,'O%T- OF C'ON18 RUCTION
1,74,06.50
r.ERM11 1 fi:P SUMMARY
CIONSTJiUC'I Y)w 1''M 01;'' d'W-X119.000 $"2.00
PLA3N' (:L j'.C% FEE =0312
1bfbCHANICA L FEM €01-000-421-000
-.101-4c204VIO S18S>07
L0
P1-;I.IIv1LINI RMS 101 -MG -419.000 $260.00
S Erofo matiaN :ax -0 101-060441-000 St. 41.
G ADIN YI,. U: .101-0004D-000 5,44 00 ,
.gild l' tri i?f113TAC PLACES -'RF-91r, 701
p .
-Ail ' IN laUBLIC L,Aoti - lfl 8W 701-000-255-000
U, CONaTr't IC'1ltJN AND PL, AN CHECK
SUB -TOW
fir. � a.2.3o
L.L�Sfi P3'.��1CI41.1� F�:L35
-$435,29
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
��
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
0 .
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
_L
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
U.
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
Q-/
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
(' _ (l!L_
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)
COMMENTS:
f
Building
Address
OwnerA
Mailing
Addres
GOntractor
ress
Zip
State Lic. I City
& Classif. Lic #
Arch., Engr./��
Designer
Address �T7/
P.o. BOX 1504 -APPLICATION ONLY
7&10�%ALLE ESTADO
,,;CALIFORNIA 92253
I y� 71 V I Lic. #
LICENSED CONTRACTOR'S DECLARATDN
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70001
of Division 3 of the Business and Professions Code, and rmv license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city c=r county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to lila a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he 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 dolars ($500).
(' 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 saI3. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or Oirough his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-7uilder will have the burden
of proving that he did not build or improve for the purpose of sale.)
L 1 I, as owner of the property, am exclusively contracting with 4censed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sElf-insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (:'ec. 3800, Labor Code.)
Policy No. Company
F3 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURAMCE
(This section need not be completed if the permit is for one hurdred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
Subject to the Workers' Compensation provisions of the Labe Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGEN0
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed anc validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant —Date—
Mailing
ateMailing Address
City, State, Zip
BUILDING DIVISION
JILDING: TYPE CONST OCC. GRP.
(�1� 1
P. Number - 5%0 -- 0 7 f
Legal Description
Project Description
Sq. Ft. No. No. Dw.
Size. Stories Units -
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. O
Plan Chk. Bal. f
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances: -
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Stree*L ck from Center Line
Side SetbZl from 90--imbAy4me
FINAL DATE .11�51 INS
Issued by: rII Datem L/ + 9 n 1396
Cermit I Il
N � n
Validated by: ip 9 ;
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING Fit ; T
IST FL. SO. FT. $
2ND FL. SQ. FT,
POR. SQ. FT. C?
GAR. SQ. FT.
CAR P. SD. FT.
WALL SO. FT. ¢
SO. FT. R
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM `
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP./EQUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11A c
SEWAGE DISPOSAL
SO.FT.GAR n I/,c
HOUSE SEWER
REMARKS:
VENTILATION
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST, FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING& AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
1UN"b blUNA 1 UlitblINI I IALJ
GARDEN WALL FINAL
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 10/8/96
No. 14908
Owner Name Minstrelli Construction
No. 50280 Street Indian Camp
City La Quinta
Tract # Lot #
Type of Development Single Family Residence
Comments
nit
,2847
APN # 769-550-051
Jurisdiction La Quinta
Zip 92253
Permit #
Log #
Study Area 125
Square Footage I
No. of Units 1
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:
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies ,that school facility fees imposed pursuant to Government Code 53080
in the amount of 628.00 X 1 or $ 628.00
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/First Community Bank/Ministrelli Const.
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson
Signature
QJAUAA_L PLOXA��.
Telephone 564-7818
Payment Received $628.00
Check No. 067203
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
1
r
Payment Received $628.00
Check No. 067203
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting