9904-045 (SFD)` LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaptert9 1�ommencing 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
7 , 361• jy av31;00
� )pate Signature of Contractor
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 . / " r/( )
1, 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 oCperjury, one of the following declarations:
O I have and will maintaln,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 LfNir%ikc:%�:1N + GC} Policy No. °..D
(This section need not be completed if the permit valuation is for $100.00. or less):
O I certify that in the performance of the work for which this permit is is'sued,•
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 provisionJs of Section 3700 -of the•Labor
Coe, I shar forthwith. comply with those prowl§ions.
ate: f 1 :7.(. `/°i 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 Lalior 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 issuedas 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 cancellatioh.
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, tinrspe}cc Ion purposes.
Signature (Owner/Agent)` S ��— `Date
V
PERM
, �,� �►�
BUILDING PERMIT
DATE VALUATION S-1..0,072.110 LOT 67 TRACT { 26.152 `
CA
JOB SITE .41-640 VIA A110NIAINA,
APN 44:5-1 W-039
ADDRESS-
OWNER
at."
Ai't4
CONTRACTOR /DESIGNER /ENGINEER
N COMPANY
1;LT.r
% hi . Ii�47a
XtiADA'A
i 570:LROOK t1OLOW JUIVE, STT208
IIIVE, SUrm 2R0
1370PM, KH71:G' DR8
SAIWANA 1.
C 92705
S1tiIA,,A1 I A 92705
014Y7,51-9151 t".tLN 4183
USE OF PERMIT 1
SINIO1LE FAMILY` FJ V*P_- 190
.t
1,1..1:1. X01. t+LikN tibl. <<tsA,► 01.kk�N WALLS
OR i'00.t L. 11.A14 CHECK FEE tt7: )1X,.ETJ 7.5%.ir•0k.r'viU8:f1,LNt.E I SSUAT+iCE iD:F
9 A -A& PLAN TYPE
:#:RU C"�'.0014511.it:6.;C:3.€Clivi 2.xd, -OSi .a
I1 l�.t`EUi?Ai ICS 33(1,1;0 Sr �
- ' • ��1"t"tACl1�e::,�tZt%t1i�t" • - ��ES".tiU Sq= �
-
•_, ,b.��a�s
.v,CON WIT,
6.1107' v e
hr-STiMAT-1;s�031
AMAE491UNIygAA'.
• ' ��:�Atw�'�RLt+tet°i�:r14 f^� _ 'i.C+:i-Oi911-4"!:£S-S1iit) . �ai'7!:►.(►
PE>AI' C£3WN: ] . !.Qt.9 R
e. r� • v fa?t c,y. l' mY r' 039 'IS
ri El y tt^k: .. 101,000-421-000 Mrs-
XTIbC.AL Mi, t0l-43i1t} 2i�-UCS 1 5381 1t7
`aiTf2OY•�4t R�d7 �iQI�1' ��i': ,`a:iD 1:��,w�(?-�Aa-1��f} $16.5.1
—QRAD1,NQ i i!Jz, 1,01-0004.23-00 $2a,tso
(iN1 •P.ieL13T 1 UC i" )XK 4. ,2X25 -M-443-342
ART ;04 (ib;1431:AC PLACX$ f?LS.r.L` 7d9.t •�1ti�7.�S �3�1 � Sfa2.fis2
SUB-TOiii (7,01K," `l I 1CANgT� pt.Ay j .��!
$5,31
7�r_1i(i�1C
�GG
ESS ND
rni. t
TOTAL PERMIT FERS MW NOW
S.5,061.12-
4REC\[N14' DATE'
BY i
DAT
IrtTk)
INSPECTOR
�( `�V"
lip
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
,Set Backs
Underground Ducts
Forms & Footings
jr 100,
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—2)—
Exhaust Fans
O.K. to Wrap
_ F -7
F.A.U.
Framing
7 _ _ FIF S` 7
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
�TZ2,-
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
C, k
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
i�g 57
Appliances
Final
Final— .,per
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) /� 1-
COMMENTS:
.n',.,y�+x't""•Ya.'�iri��`f'a'pp�i°+� e�i,-�,j'�}r; �r-}��y�r�•'tg�.-g`�diG�'0+>�"T''r"`f�aiv:",a�.s� .�...
4,7_&46 �I A MOt11'fWA P.O.4Q"
Building 78-495 CALLE TAMPICO
Address Cltn6k) 014{01etlr-e*_ O
LA QUINTA, CALIFORNIA 92253
Owner
(NC V%r (�
.�
Mailing t
Address 1 370 Rfmtboa :w 40
,CityZip Tel.
�pVcx A �� �9,- ,' 719 75 LIKI
Contractor
Address 1 I
J1a1e LIC.CG-6 1 a.rty
8 Classif. J f i,S a Lic. #
Arch., Engr., I
Designer
Address Tel.
City Zip State
Llc. fi
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9'icommencing with Section
7000) of Division 3 of the Business and Professions Code, and my 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 or 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 rile 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 or not more than five hundred dollars ($500).
1] 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
Duiltls 0,
improves the and who does such work himself or through 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 -builder will have the burden
of proving that he did not build or improve for the purpose of sale.) -
I I'l, as owner of the property, am exclusively contracting with licensed 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 rimproves thereon, -and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
r
i 7 1 am exempt under Sec. B. 8 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. (Sec. 3800, Labor Code.)
• Policy No. Company
+ r] Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner i
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions - of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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 h
This is a building permit when properly filled out, signed and 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 a0plicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE CONST. �IV n OCC..GRP.
P.
A.Number 6043 - I Zl'//03 p 1 f(
Legal Description Lac
Project Description
'::�6(A h E3
Sq. Ft.
Size
New ❑ Add ❑
sumateo valuation
a I
PERMIT r
Plan Chk. Dep. ;
Plan Chk. Bal.,'
Const.
Mech.
Electrical,
No. No. Dw.
Stories Units
Alter ❑ Repair ❑ t Demolition ❑
I
AMOUNT
Plumbing
S.W.
Grading
Driveway Enc.
(Infrastructure
--------------
1
i
TOTAL 1
REMARKS .R
r
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Piop. Line
Side Street Setback from Center Line
Side Setback from PropertyLine
FINAL DATE INSPECTOR
Issued by: Date Permit
a
Validated by: +
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 4/15/99 APN # 643-120-039
No. 18576 Jurisdiction. La Quinta
Owner NameLake La Quinta Comm., LLC " Permit #
:t
NO. 47-640 Street Via Montana Log # "
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 2713
Type of Development Single Family Residence No. of Units 1
Comments
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:
EXEMPTION NOT APPLICABLE.
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 2,713 or $ 5,236:09 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/Life Bank - Robert Walker'Telephone°771 79636;
A.
Name on the check Fes` V A '✓k .
By Dr. Doris Wilson
Superintendent t ..•
Fee collected /exempted by Ellen Patino Payment Received 14r; , "236.09
Check.No. 4400313
Signature
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
Dove will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
Dllect them on the District('s)(s') behalf, whichever is earlier. 1.
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
a
PUBLIC WORKS CLEARANCE LETTER
FOR
CUSTOM .HOME LOTS
Dear Builder:
Prior to issuahce of a building permit, you will be required to obtain clearance from the
Public Works Department for one, or more, of the following:
1. Verification that rough grading is complete, and the pad elevation certifications
prepared by a licensed surveyor, or engineer, are on file in the Public Works'
Department.
2. Verification that infrastructure improvements and other.required tract improvements
are complete, or, sufficiently advanced to warrant building permit issuance..
3. Prepare an engineered grading plan that provides for on -lot storm water retention,
and have.it checked and approved by the Public Works Department.
• Tract 26524 (Estancia§)
• Tract 26769 (Mountain View Estates)
4. Prepare an' engineered, grading plan .that provides for building pad grading in
accordance with the existing soils report and tract grading plan', and have it
checked and approved by the Public Works'Department.
Tract 28034 (South Valley Estates)
FOR INTERNAL USE BY PUBLIC WORKS
TRACT:
LOT: 7
PUBLIC WORKS AUTHEIRIZATION 16ATE
F:\PWDEPTRDOCS\FORMS%PW CLEARANCE LETTER.ss
COMMENTS:,