9601-010 (SFD)LICENSED CONTRACTOR DECLARATION -
I hereby affirm 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. *W234. 13 ` 12/319.5
License # Lic. Class Dgta
'(Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) 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 Cade).
() 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 Policy No.
(This sectlbfiiKeednbt % completed if the permit valuatiofi;is f6644 00.00 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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thos pMy� Date: / t/,_g (a Applicant ��A
-'-s
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 be 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 resyiItrof th�is•-�T-),DIIcapYon agrees to, & shall, indemnify
& hold harmless the City ofd"India VYells�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.
s
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 iinnspec ' • n pur oses.
/Signahrre (Owner/Agent) l �-� r 4 Dame /-% '146
ALC0
^r
.- _BU.ILDING PERMIT
PERMITyb01-010
DATE �� �►
VALUATIONtC00 •`'4 LOT = TRACT
JOB SITE ADDRESS 791-175 LAI IGO CIRCLE,
APN 604_263-020
OWNER
CONTRACTOR
R(.. sER. SNEI.L:ENRI RGER & ASS
R.001rF- R S1L'EL. FNTEIIE .GER, & ASS
41865 BOARDIN ALK #212
41865 8( AIX #212
1 PALM DESERT CA 92211
PALM DESERT CA 92211
(619)777-7766 C.kIL# 1858
i
INSPECTION RECORD
OPERATION
I
DATE
I 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.K. to Wrap
47
Exhaust Fans
F.A.U.
Framing
L
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
6
Drywall - Int. Lath
Final
BLOCKWALL
Ao
PPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
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
Final
Utility Notice (Gas)
ELECTRICAL
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)
A • PROVALS
COMMENTS:
Desert Sands Unified School District
i�T..¢•,.,. 82-879 Highway 111
01
Document Cannot Be Duplicated Indio, CA 922
619-775-3500 2
CERTIFICATE OF COMPLIANCE
Date 1/3/96
No, 14004
APN # 604-263-020
Jurisdiction La Quinta
owner NameRoger Snellenberger & Associates
No- 79175 Street Latigo Cir
City La Quinta Zip 92253
Tract # 23913 Lot # 11
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area 233
Square Footage 2132
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:
EXEMPTION NOT APPLICABLE
9
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.72 X 2,132 or $3,667.04
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 Roger Snellenberger & Associates
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature POL, i 01110 P111At6'YN_
Telephone
s
Payment Received
Check No. 10634
$3,667.04
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
,)