9712-089 (RER)I' LICENSED CONTRACTOR DECLARATION
U) µl hereby affirm under penalty of perjury that.,,, lic "Sed under provisions of
I—-Qhapler 9 (commencing with Section 7000) o('Dlwslo 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O :5 License # Lic. Class Exp. Date
r,- Q U.)
W
oZ r-- Date Signature of Contractor
O�
r- U C) OWNER -BUILDER DECLARATION
HWW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole
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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 -- , . f Signature of Owner t
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 section need not be completed if the permit valuation is for $100.00 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thostprovisions.
- , r
Date: . y r, - : - � Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) , t / Date i
BUILDINGPERMIT PERMIT# °°NTRDL#
DATE 12/19197 VALUATION % q40 f)0 LOT TRACT
1,66-24
JOB SITE
ADDRESS l�S 79-224) DIAE DRIVE APN 604-33341%
OWNER CONTRACTOR / DESIGNER / ENGINEER
t; lT.ri;)";�' i�. t�.l`:r"s'' f �`" v asrnr Dfi,
M-22Ci MANE OR
16, QUINTA CA .92253
C�i1Ji: 1
USE OF PERMIT? 2
Cti,NIVERT 3RD :B471 07F CAZCt1.G,-8 IWO lire 5.i . M -NUS ROOM
DEC 191997
CITYOF
13.fJAIN' Cf LI.CiC.F EE 101-t$CI(I•=39.31 R
.i a C=It`% 4'ltr,AL it,3ri l.fle°.'V�"'i�.�i-1)V,
' 1:• (I
ti'p'Ir'.t-.IAfC.i.W:f;CIO'N 1T:E [07. 11) 101 -000 -241 -OW bb.fil)
SI 9 -TOT -N, CONSTRU(.7—nON AND PIAN CI W -Cm
f "SS
RECEIPT DATE BY R DATE FINALED INSPECTOR
. / _
$14)2
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
r
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation -4q
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 APPROVALS
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
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
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Rnal
Utility Notice (Perm)
COMMENTS:
M
OWNER / BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78495 Calle Tampico
La Quinta, CA 92253
(760)777-7012
FAX: (7 777-
12
OWNER'S SIGNATURE/ DATE
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PROPERTY ADDRESS
q�12-om
PERMIT NUMBER(s)
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ONUS GARAGE
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CT �OF AGS6NTA
BUILDING & SAFETY DEPARTMENT,
CONDITIONALLY
EPARTMENT-
CONDITIONALLY
ACCEPTED FOR CONSTRUCTION
SUBJECT TO INSTALLATION AS PER
f AND ALL APPLICABLE CODES
1
I Z - BY .%
Desert Sands Unified School District
Notice: 82-879 Highway 111 "\
Document Cannot Be Duplicated Indio, CA 92201619-775-3500
CERTIFICATE OF COMPLIANCE
Date 12/19/97
No. 16421
Owner Name Anthony P & Angela L Toss
No. 79220
City La Quinta
Street Diane Dr.
Tract # Lot #
Type of Development Residential Addition
Comments
)onus room conversion
APN # 604-313-006
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area
Square Footage 200
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 200 or $ 0.00 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 n/a Telephone f
Name on the check
By Dr. Doris Wilson Y -
Superintendent ?
Fee collected /exempted by Pauline Pearson Exempt r, $0.00 •,'-
Check No.- n/a
Signature
IOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
bove will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
ollect them on the District('s)(s') behalf, whichever is earlier.
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
i
a
_ r CITY OF LA QUINTA
BUILDING & SAFETY DEPARTMENT
777-7012
INSPECTION REQUEST LINE
777-7153
Owner TONY ROSS
Contractor HENRY YANEZ MASONRY
Permit Number
POST ON J
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS 79_110 DIANE DRIVE
NO FEE RETAINING WALL PERMIT FOR
REAR YARD 77'@ 2'8" RTN
TYPE OF INSPECTION DATE INSP.
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT- A/C
FIREPLACE
ROOF 17
BOND BEAM
O.K. TO WRAP
GROUT O 4' O 8'
FRAMING
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR
EXTERIOR LATH
POOL. PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC TANK
ELECTRICAL
PI I IIu nmr;
FINAL GAS TEST
HEATING - A/C
TEMP
FINALS
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING