9512-014 (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. 4=34 12i 3195
License # Lic. Class.-..— L Exp.. Date
Date 12.]ti. rt. Signatureof Contractor- __L
OWNER-BUILDER DECLARATION
I hereby affirm 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 ofOwner
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:
Carrie; Policy No.
(This section need7r of g completed if the permit valuation.is,fpr 00.00 or less).
() I certify at In the performance of the work for whit 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 3700 of the Labor
,Code,.I sF1all forthwith comply witJi_those provisions.
Date: 171519$- 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, intarest 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 application agrees to, & shall, indemnify
& hold harmless the City ofLndian alerts 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 informationfis
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 proper for inspectibn>purposes:
Signature (Owner/Agent).-�^^" Date f
1A`c" � BUILDING PERMIT 1PERMIT95d2-0t4 1
DATE 1X/4f9_S VALUATION S14%.z5o.6o LOT 17 TRACT 13913
JOB SITE ADDRESS APN
70-190 1.,ATIGO CIRCLE 604-.263-014
OWNER CONTRACTOR
ROGER .4-kL l.E BERGER & _ASS
ROGER SNELI:e1`JU R GER St ASS 41865 UdA.P.TWAK 9212
41865 BOARDWALK H212 PALM titSERT CA 922.11
PALM M DESERT CA 922 U (019)'777-7766 CBL# 1858
(619)777-7766 DESIGNERIENGINEER
USE of PER""T�INGLF FA1'l1i .
Qt.)1.N'.[7r:R1tA
',K AN 3R
FEE D
T RACE C7ONSIRUCTTON 2.359.00 SF
PORC'11lIt'ATIQ 49.00 SF
GARAGFJCARPORT 587.00 SF
ESTINIAT.ED COST OF CONSTRUCTION
FERIA IT FEE SUMMARY
'PLAN aTECK FER
101.4M439.-315
$619
CONSTRUCTION F'T'C
101-()r)0-418-000
$783
NX,CHAWCAL FEE
101-000-421-000
$68
ELECTRICAL FIX,
101-00()-420,000
$152
PLtMINrP FEE
101-000-419-M,
$174
S"TONG MOTION .Fhb - RESW
100-000-241-M
114
ORADINO . -IM
101-000.423-000
$20.
INFRASTRUCTURE blM
125410(? -443-342
$3,140.
ART IN PUBLIC PLACES - RESTL 701-000-255-000
$100.
93
00
50
81
M
03
00
98
63
140,250.60
SUB -TOTAL CONST tUC;'iON AND PTAH CHECKI $3,113.811
� LESS PRF -.PAID PEES $0.00
DF�07199
5
RECEIPT
TOTAL PE.RSHT FEES DUENOW
TE RNALED
INSPECTOR
$5,113.88
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 (
Exhaust Fans
O.K. to Wrap (p60,ol
F.A.U.
Framing 17
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
Final
BLOCKWALL AFOROVALS
POOLS - SPAS
Steel
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out 7
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping iv
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
Utility Notice (Perm)
0
Notice:
Document Cannot Be Duplicated
Date 12/5/95
No. 13936
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner NameRoger Snellenberger & Associates
APN # 604-263-014
Jurisdiction La Quinta
No.79180 _Streety-Latigo,Cir:__
City La Quinta zip 92253
Tract # 23913 Lot # 17
Type of Development Single Family Residence
Comments
By
Permit #
Log #
Study Area 233
Square Footage 2359
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
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.72 x 2,359 or $4,057.48
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.
`1 r+
Fees Paid By Roger. Snellenberger & Associates, Inc. Telephone
Name on the check
.T ,w
Dolores A. Ballesteros
Superintendent 'l; r
Fee collected /exempted by Pauline Pearson Payment Received $4,057.48
Check No. 10308
Signature.
a
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
J