9701-020 (SFD)LICENSED CONTRACTOR DECLARATION
Cl) I hereby affirm under penalty of perjury that I am licensed under provisions of
�, 4. Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C\1 utr Professionals Code, and my License is in full force and effect.
p `n CO License # Lic. Class Exp. Date
Or �►�i7i32 1;
LL] I v�
Z r, /DateSignature of Contractor"" •!- f �'r r ' "f
Cn 0 n C cf r... .W
cTO—
�
0) r OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ � License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O�
U Q 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
Sec ion 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 Policy No.
'LU:IGt4 INS. CC), WC6I1.11"6?tt_'+
(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
stibject to the workers' compensation, provisions of Section 3700 of the.Labor
Code, I shall forthwith comply with those provisions.
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 representatives of this City to -enter upon
the above-mentioned property for inspection purposes. � 4'
1 1•2 J .4 r
Signature (Owner/Agent) . -, !f �� ,� -nate?✓?
" PERMIT# CONTROL# 1
,BUILDING�PERMIT yT-��j
DATE n LOT a ;
TRACT `4,87JOB
SITE
ADDRESS CF -W JACKiVIi.iA.�JAUS i34�13��i�Jt'AR0
APN 76Y-iYii-0�
r OWNER
CONTRACTOR / DESIGNER / ENGINEER
KS). LAND it
K�SL COR
P
564.1011GA. HIND. !
�D�_E_VELOPMENT
56140 1100 BOULEVARD
LA QUI NTA CA 42253
LA QIAYrA CA 4225:11,
i%f 1771-WAI C13LO
USE OF PERMIT
SPI)
PGA WF.ii , - MW ! i Ii P[.t\N 2II
PLAN PIIIF .;iFOR Wi.,api.T: ISSUR OF SANiF PLAN
CU> t01M CONS'TRUC11014 2,972.00 71'
1101teWPATTO ;4S4,06 SP
(;ARA(;1JCAI2P0R T E+77.1lt1 Sig
03TiMME1) MST OV C', 3NSTIR,IjCTION
241,839.20
3'MAiIT FEF, NVAiMMOV
CQNS'rR1 . M ON FFE 101-000418-000 F. t3ri. it3
II'�It,AN r,t,+fi� Fr111!rte 10y1-(0'�(M(�?•0�n9-(3(19..
A4LC IANI�i..AL i'L.UN 101-OW421-000 M+T,�.f7Rl
Cil.#:t::4`I %At.VUS 101-{)00-420.OW 1I^1 sti
P ION4BINCi 17EHt N 10(-000-414-000 317y:
3'('1+'.of-4"fN10-'ioN{R4?Ss 101-�(��=.'.�i1-0( 'It' -4.Z8
(M. -WING 101-000-123400 $2U.00
41vi�TtA`+1'1jc:4'1}ftli r�2��11'r0-�1�-��� x4,32:4F
Alt.'4 Tib MJSJA(- Y1, r,%. (RWS)701,000-255-t)M) S354.66
}
t1�7 �r 4TAT C4hi51'RUCT'ION .AND PLAN CRI=CK
$7,S3a,�47
a ' LESS PRE-PAYD RES
S0.00
MAR 2 7 '1997 1d)Tli1�► T€i�11 i �Fr1'.�I n)1�. N%t4%
Si�„C3q.ali7
^4TH 'tOF7 "A+�l3�+�`—tt?-N
RECEIPT
DATE
By,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APP OVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Al
Ducts
Slab Grade
(p
Return Air
Steel
Combustion Air
Roof DeckExhaust
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
D II - Int. Lath
/
7
4(44
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
a
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines%will
LZ
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
1,rl 71 7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
'
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 7
Utility Notice (Perm)
Coachella Valley Unified School District
83-733 Avenue 55, 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:
DATE:
RECEIPT:
CHECK #:
rMTIALS:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Bob Edwards Construction
Owner's Name: _Bob Edwards Construction
Project Address:
Project Description:
56-340 Jack Nicolas, La Quinta, CA 92253
Detached Casita
APN: 762-070-032
Tract #:
Date: August 3, 2005
Phone No. (760) 777-8202
Lot #'s:
Type of Development: Residential XX Commercial Industrial
Total Square Feet of Building Area: 487 Sq. Ft.
Certification of Applicant/Owners: The person signing certifies t at the above information is correct and makes this statement under
penalty of perjury and further represents that he/she is authorized t sign on behalf of the owner/developer.
Dated: 08/03/05
Signature:
******************************V****************************************
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
17620 65995 Approval Prior to 1/1/87 Requirement
Number of Sq.Ft. 487
Amount per Sq.Ft. $ 0.00
Amount Collected $ 0.00
Building Permit Application Completed: Yes/No
By: Carey M. Carlson, Asst. Supt., Business Services
'Pursuant to AB181 Any room addition 500_so. _ft. _or less i_g.
exempt from developer feesl�
Certificate issued by: Leticia C. Torres, Facilities Clerk Si
NOTICE OF 90 DAY PERIOD FOR PROTEST OF PEES AND STATF.P61ENT 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 of 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.
4t4`.cimgdnc:� ;ovfcis:`cirlit7cair ofwnlplianec fonn tablesTO 11SF.doc:
6
1/16/03 T
10.1
Certificate-pf Occupancy
City of La' Quinta
Building and Safety Department OFTM
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 compliance with. the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 56-340 JACK NICKLAUS BOULEVARD
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9701-020
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: KSL LAND II
Building Official
Address: 56-140 PGA BLVD
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR.
Date: 9/24/97
POST IN A CONSPICUOUS PLACE
PR v 30'N TANDY
3580 Condalia Ave.
J ewpa Valley, CA 92284
(619) 365-5045
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF ❑ REINFORCED CONCRETEC0/STEEL ASSEMBLY ❑ O
INSPECTION ❑POST TENSIONED CONCRETE ❑ ASPHALT 1THE
PERFORMED ❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION J6-34e)
6_3LT/ J,46A �� �� J\`;/n 74 REPORT SEQUENCE NO.
TYPE OF STRUCTURE �j/ ` PERMIT NO. /VIIJV D21-7_1-7 DAY OF WEEK
MATERIAL 4CRIP O ARCHITECT INL7IPE 04 HRS. CHARGED
�LIJ cc::J(J( � /T
C7 04 7_7 ENGINEER ASSISTANTS HRS. CHARGED
INSPECTION GENERAL " SUB
DATE CONTRACTOR— S• - CONTRACTOR S C•t�Z�o ( �" `}-
4 dF 4514.5E-
S�/
Ts. 6-xioX'/ �2aLs
E E R'. -7 ; 113E- 0 P -P 4 0 EZ
g6j.5ivE FS r.v, gas -
COPY SENT TO CLIENV ICONTINUED ON NEXT PAGE O 1 PAGE 0F/
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE 1
GOVERNING BUILDING LAWS.
e
�IGNATU E Of GISTER IN$PECoT e / 9 r)5
TE O EPORT REGISTER NUMBERUMB{EERRR