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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury 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.
License # Lic. Class Exp. Date
04074 1; /--,�t,1;;
Date Signature of Contractor`� 1�.
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, 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).
( ) 1, 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 s r F 1,L k CN1.) Policy No. l.; r �l'1r yvy
(This section need not be completed if the permit valuation is for $100.00 or fess):
( ) 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. _
Date: 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, 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 applicator agrees to, & shall, indemnify
& hold harmless the City of La Quinta, 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 propertyG forinspection pii rposes: f
{� �� �,,,� � S� ,; it •.
Signature (Owner/Agent)-1 (r - Date •��' /
BUILDINGPERMIT PERMIT# • CONTROL#
3089
DATE VALUATION LOTtfhi'�i / TRACT
JOB SITE
APN
ADDRESS
79-665 M;`s4:AN:SO
:(04-4)20-003
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ice;o�::%i.'111
Fc i io
RANCHO 1:,A'0jJfX AUR,.
LA cVl,ft.1`J'IA (.IA 92253
LA QUiNTA (,A 9.2:253
USE OF PERMIT
Ai 0111'10N
0.1Ai'rt/'taW1' CCIVEREL PAY10'. O C0M?f`t.(0NW SPA £.
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CIOXSTUIKI'110NR1.3t01•i�i!il-/t:1&4{)0 $ �.Of
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KL8C['RTC1V1,1°'}:F: $19.92
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SU13-Tf.Y?'r L !"G'NS"�'"UK-7If�+N AN"D PL A14 CHECK K
$182,99
LESS. .1IRLE-PAX) FEES
$0.00
TOTAIJ PERMIT FEE' S DUE, NOW
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
Pik 61:1 *64 061k9iff 14 X.0
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL• APPROVALS
POOL_ S - 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
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 APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Service
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 4/12/96
No. 14325 Jurisdiction
Owner Name Daniels
No. 78665 Street Descanso Ln.
City La Quinta
C(ap'y
APN # 604-020-003
La Quinta
Permit #
Log #
Zip 92253 Study Area 123
Tract # Lot # Square Footage 112
Type of Development New Residential Addition No. of Units 1
Comments
enclosing a patio
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.72 x 112 or $192.64
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 TD Desert Development
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Exempt
Signature , &"J'- Q' (�
Telephone
Check No. 1542
$192.64
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