9601-003 (SFD)M
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`q' 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. 4R9234 B I 12/3/9-5
License # Lic. Class
Date I- Signatureof Contractor 16 1 G'
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 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&PC. or thi .reason��
Date -"'T . Sig natujeofOwner
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 sectiiop�T9ggr1,qjjD completed if the permit valuatioals fo J$ 00.00 or less).
() I cer4fy 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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with
�hision�/fDate: ApplicrZt ot
.0
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 resukpf.this appplicartion agrees to, &shall, indemnify
& hold harmless the City of Indian -Well's, 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 inspec.'on purposes.
ignature (Owner/Agent) r/ Dams
ALcr
BUILDING PERMIT
PERMIT;„Ii-„3
7
DATE J/3/96
VALUATION .$81>��,�g�,��
LOT 1i
TRACT 1%
JOB SITE ADDRESS
APN
79-19.9 LATIGO CIRCLE
604.2631-018
OWNER
CONTRACTOR
168,”
ROGER SN.ELLENBER-GER, Ll -ASS
RODE. Z. SNELLEMBE1t.GE11 & ASS
41$65 BC)A1ti7` fA.LK 9212
41865, BOARDWALK. H21a
' PALM DE'SEWr Ctk'92211
PALMf misraT CA 9221 i
(619)`777»7766 CBLII I1tyx
DESIGNER/ENGINEER
(619)77-7-7766
S"CONTQ N101` ON FEE - RESED
CHARLES D. GfMd.
CATf)tilNI,°31 D,'.2.
33-161_ O,1Z
USE OFPER""T NGLEFAMILYDWELLING
QUINI MA -'#RAC I! 239.13,PHASS It
FLAN i -
FEE D
i'1tACC' C 1Ns'I'It:L)c; TION 1,968.00 Sty'
GDARA43GfCA12lyOH!f 58:3,00 SF
. ESTIMATED ED COST OF OO,NNST R>LiC`11'[ON
118.289.20
-PERff ITWE 8MMARY
7
PLAN CHECK :Fi^R
101-000-4439-31,8
$595.43
COMSff tSCI'I0NFEE
101-000-415-000
$706.00
WCHAN1CAL FT -13.
101-000-421-000
168,”
FlEC'MCAI,FEE
101-000-4'0--000
$744.01
P..LUMBING3 FES
101.-004-9-m
PWOO
S"CONTQ N101` ON FEE - RESED
100-OW241-00.0
t I.83
GRADINGM- C
101-000423.000
520.00
WIASTRUCTURE FFY,
225-000-443-342
$2,667.5.1
AIRT 1N 1 YRIC PLACES - MOM 701 -000 -?55-000
X25.22
r �
,
SU13 ' ' rm. CONSTRUG"1 ON A.ND PLAN CHECK
LESS PRE -PAID FS
TOTAL PERMT FE ESME NOW
RECEIPT- I DATE BV DATE FINALED INSPECTOR
$4,385.53
$,0.00
$4,385.53
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
7j `2(74
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
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
i
Final
Final
BLOCKWALL PP OVALS
FOOLS -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 APPI1vVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
U
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Paas
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final '
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) �
COMMENTS:
;
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Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
61 t6l1(!
CERTIFICATE OF COMPLIANCE
Date 1/3/96
No. 13997
Owner NameRoger Snellenberger & Associates
No. 79195
Citv La Quinta
APN # 604-263-018
Jurisdiction La Ouinta
Street Latigo Cir.
Zip 92253
Tract # 23912 Lot # 13
Tyne of Development Single Family Residence
comments
Permit #
Loa #
Study Arca a 3 3
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 uursuant 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 ; jelepkone,77-7766
Name on the check
By Dolores A. Ballesteros
Superintendent "►�, u t-;
Fee collected /exempted by Pauline Pearson Payment Received $3,384.96
? Signature l` J , � I v LpAI A—
Check No. 10634
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