9512-012 (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. 48},-234 8 12/3/95
License # Lic. Class Exp Date
Date tzj K q C Signature ofContractor''i, o 5
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 of Owner
r r
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 sect' t�ogedfr�tt be completed if the permit valuatiop.js,joa 100.00 or less):
() I certify t at In a performance of the work for whicA 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 shall forthwith comply with4hoserowslons.
Date: Applicant :.. ��.r _r•,`
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 application agrees to, & shall, indemnify
& hold harmless the City of I641ann lls,611s 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.'
— �---� t
Signature (Owner/Agent)._
"`C" f ,BUILDING PERMIT PERMIT9��� a2
DATE 1.2/ 41!)5 1 VALUATION/ X1,13,Z89.21ll LOT Ib TRACT .3913
JOB SITE ADDRESS APN
79-1901.,1' IG10 CIRCLE aiiat 263 di�:i
OWNER r CONTRACTOR
ROGER SNELLENSER.GM & ASS
1'.Otx`Elt SIREI.I.E i�ERsJE€ &ASS 41805BOAP£}L ALK 9212
41863 BOARDWALK #212 PALM 13ES'EWr CA. 92211
PALM. DESEWr C.A. 922.11 (6.19,)777-1766 CRI..# IM_
(619)777-7766 DESIGNER/ENGINEER
rW.IILES D. CARL MD
USE OF PERMIT
INGLE FAMILY .DWELLING 33-163 CATRM)RAL C19,J DR.
QUIN HRRA.
'PLAN IR
TRACT CONNSTIkLICTIGN
GARACTICARPORT
1.968.00 3
.583.00 Sl;
ESTIMATED COST OF CONSTRUCTION
1'I+JltMff FEE SUMMARY
PLAN (Wl CK FIi1
101-000-439.318
$595.43
CONS T RUMON M-113
101.000-418-000
$706.00
MECHANICAL FES
101-M-421-000,
SM50
ELECTRICAL FEE
101•-000420-00()
$144.04
P1,13 RING ME
101 -OM -419-W0
M50! .0
STtaNG.NMOT.IONFEE .1ZE",1D
100-000-241-000
$11.83
CRADINO FEE •
101-000.4'23-000
$20.00
RVRAST RUCTUl F, FEE
M-000.4433-342
$201,51
rlRT IN PUBLIC PLACE'S - Remo 70i, -ma L55-000
$28.22
SUP -TOTAL CONS�`RUC'I lON AND PLAN CHECK
1,13 SS PRE -PAID FEES
C 'OTAL P1G[tw rf FEES IAJE NOW
DEC 07.,1995
CEIPT I DATE . ".... 1BY JDATE RNALED II
$4,385.53
$0.00
S4,385.5:1:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deckij
Exhaust Fans
O.K to Wrap _
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O. L
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall ;
Exterior Lath ,
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
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:
Final
Utility Notice (Gas)'
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power,
i
Final
Utility Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 12/5/95
No. 13935
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner NameRoger Snellenberger & Associates
APN # 604-263-015
Jurisdiction La Quinta
No.`�90
19a��Street—Latio Cir—,
g_�
City La Quinta zip 92253
Tract # 23913
Type of Development
Comments
Lot # 16
Single Family Residence
Permit #
Log #
Study Area 233
Square Footage 1968
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 1,968 or $ 3,384.96
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, Inc. - Telephone 777-7766
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,384.96
(� Check No. 10308
Signatureylv , , ! L y n, A A .nnv
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