0209-240 (CONR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat I am licensed under provisions of
Chapter 9 (commencing with Se 7000) of Division 3 of the Business_ and
Professionals Code, and my Licensewis 6 full force and effect.
License # Lic. Class Exp. Date
7117699
tvDate Signature of Contractor
4t
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).
(✓al am exempt under Section B&P.C. for�thireas nVrDate Z,- • ' 'Signature of Owner
r 1�
WORKER'S COMPENSATION 0E�GLARATION
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:
Cartier Pr intEmmonm Policy.No. IVLR.C430?A318
(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' compensati'on provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thosp r visio S.
Date: ' Applicant -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crimina enalties 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.
J
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.
YSignature (Owner/Agent) ,�' Date
BUILDING PERMIT PERMITk '
DATE VALUATION..'! LOT IM -240 TRACT
JOB SITE %
ADDRESSoLtrlY..R,c�t.�
APN
�1SD^EYr�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TOUT, BR0TF 11W1t3'
TOM ERS :Q1TC
74.923 HOMIX!_ME Mn MY11 -2209
"14.92;
P.fis1'.M DME9,17 CL 92160*-
PALM I.M.13.%RIf CII. 92260
(160)674-9699 CBIR 3832
USE OF PERMIT
COW-9nCIAL
HOUSr.UPAt4CY ,` YP,9V*44 CONST1i:OCT.IOW
CONTRACT AMOUNT 1%am,N &S
1)TWP :f.V:)J}'RJiI.&'[..'L .
C014STRUC )ON MZ 101,000-418,000 1011.00
PLAN CHECK. 101-000439-318 �1�i1.s"d.
�dECHA�1.1C'AL ME 101-000.4i-1-0001;39.50
E-'1.,ECTPZ1C.At1. 349 101-000.42"00 544.5.0
PLUMBING FEE 101-0-00-419-000 $5230
0140 MOTION 123:C.1� - CC9l�R;M �-t900r(b1
0N
(ST
y3y}rU�O-41
�'
RADINO FEE ♦1{� /�:�i4U
(� !
OWMDPER IMPACT FEE $472. 133
ART IN PUBLIC ,PLACTO - CHOW 270.00035.000 0911€'
B -11. AL CO23 F;%1C'�iC'),1I AND SLAW (AME M
c� {LE°D P :PAID FEW
$0.00
..........
.EAL 1PER'v1yr rim 1'$•Fii c)'#'ovv
W91.35
IT'E' t ' UINTA,
FINANCITY
ECEIPT } IY�b 'e �'"'
DATE.
BY r f K
DAT I[lAL INSPE R
"1
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
/o —
Exhaust Fans
O.K. to Wrap _
F.A.U.
Framing
�`
Compressor
Insulation
_
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
fans& Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
I Y
Final
�lFinal
d-ROVALS
POOL -SPAS
BLOCKW LL A
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVA S/1
Gas Test
Waste Lines��
Electric Final
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
COMMENTS:
A
Final
Utility Notice (Gas)
ELECTRIC- ►L APPR
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
_
G.F.I.
Smoke Detectors
Tema. Use of Power
_
K.3✓
Final
Utility Notice (Perm)
--
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 398-5909 — Fax (760) 398-1224
Project Name:
This Box For District Use Only
DEVELOPER FEES PAID
AREA:
AMOUNT
LEVEL ONE AMOUNT:
LEVEL TWO AMOUNT:
MITIGATION AMOUNT:
COMMAND. AMOUNT:
DATE:
RECEIPT:
CHECK d:
INITIALS:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Owner's Name: Toll Brothers
Project Address: 51-829 Via Sorrento 80-4052 Via Val erosa.50
Project Description: 2 comfort stations and (1) guard house
772-270-001
Date: JahUdkVY27, 2003
Phone No.
-540 Jefferson La Quinta. C
APN: 772-250-011 772-250-OCI13ract #: 30357 Lot #'s -
Type of Development: Residential
Commercial ZZX Industrial
Total Square Feet of Building Area: • •1142 sq. ft.
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 authorized to sign on behalf of the owner/developer.
Dated: 2--7'1 C, Signature:
SCHOOL DISTRICT'S REQUIREMENTS FOR THE,
ACCORDANCE WITH ONE OF THE FOLLOWING:
Education Code Gov. Code Project
17620 65995 Approval
Number of Sq.Ft. 1142
Amount per Sq.Ft. $__ 34
Amount Collected $ 3RR _ 9$
Building Permit Application Completed: Yes/No
By: Carey M. Carlson
Asst. Supt., Business Serv.
OVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
(CIRCLE ONE)
Agreement Existing
Prior to 1/1/87
Note:
Not Subject to Fee
Requirement
Certificate issued by: ELyi ra Mattson Signature:
Office Technician
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 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.
M V:c/mydocs/devfees/certificate of compliance 09/30/02