0301-158 (SFD)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
/ Date Signature of Contractor,`
,
OWNER -BUILDER DECLARATIO
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 & Processionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct. the protect (Sec. 7044, Business & Professionals
Code).
('),-.lam exempt under Section Q 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 af�rtificate of consent to self -insure for workers'
compensation,' as provided for/,, 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 STATE FUND Policy No,° .134139BO
(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 tathe workers' compensation p�o�sions of Section 3700 of the Labor
Go q Ashall forthwith comply withtlose provislp, s ,.
�Date:�+ � P► Applicant—
:
pplicant �tr� (�
Warning.: Failure to secure Workers' CompensItion 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, 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,adree 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) Z M&` ;6Date
PERMIT PERMIT#
0301458
_BUILDING
DATE VALUATION LOT TRACT
71. DLK 5
JOB SITE'
b
APN
ADDRESS '.r`.'a-2—M5 AVF}.f.tDAT,%AZ
773-21.1-013
OWNER
CONTRACTOR/DESIGNER/ENGINEER
KC DFIOP11A 1•
K.C. DZVr! P_&T
SO- 145 VISTA ,(IRA,;+M�
SO-1453d'Y�'.tW 4�GRANDE,LAQ13MTI
A �f 92253
LkQUI1Tt" 0MA 92253
.0
�y
(760)578-0:125 MIX
USE OF PERMIT
1886 3.11' SYD. PF..P.M.IT LDOPS NOT INCL , DR, BLOCK WATT, P001, OR:
DWMAY 7A REDWED PLAN f1ECly FEz 1ror, muaIPu
PLANS OF MME
TRACT C0NSTk.UCT1tXN 1AW 9F
P ORCHrF.ATIO 52.00 :3F
C3ARA,C?T+dC..A11.k;O13,'1' 420,00 SAF
X.';�.`111�1D.'�°.i.�3 C;mf T OF+' CONST1iM(;aiiON
I11,333.40
F:p!MNU.0 VISE SUMMARY
CONSTRUCTION FEY, 101 000.418-000 501.50
PLAN CFRIX 101> 000-43�9-3}18 V41.f02�
gC.�141K
e
101-000-439-318
1.101HC".. 11IC.J iL, FEE 101-000.421-000 'gA.9.00
EL1 CTIUCALFEE 101-00 0-4,20-000 $122191
P11U.T•.0,10ING ; 101-000-419-000 $125.25
STRONG MOTIO)4 M1? - WID 101.000-2,41-000 111113
QRA.DBNQ Mr, 101-000-42-3-000 $15.00
DWr!. )PZR IMPACT FFF. SZ405.UU
PRYCINE PLAN 101-0004%1-345 $100.00
- T� 1`1.0 AND P'l.r' 4 cm—M
$3,660. 8 i
CITY C."'–AQU!NTA
DEPT.
RECEIPT
DATE f / ^,
BY �D
TEF ALED
INSPECTOR
i r !(� a
INSPECTION RECORD '
OPERATION
DATE
INSPECTOR
OPERATION
DATE,
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
,C/
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-tell
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
—
Compressor
Insulation�
_
FQ
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- �F
Drywall - Int. Lath a g
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
�2 a3 ��
Encapsulation
Gas Piping
: Gas Test_—��
Appliances
Final
COMMENTS:
Final "
Utility Notice (Gas)
ELECTRICAL APPROVAL
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
Final
Utility Notice (Perm)
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
Date 3/3/03 La Quinta, CA 92253
No. 24196 (760) 771-8515
Owner
KC Development
APN #
Address
80145 Vista Grande
Jurisdiction
City
La Quinta Zip 92253
Permit #
Tract #
Blk 5
Study Area
Type
Single Family Residence
No. of Units
Lot #
Unit 1 2
Unit 2
Unit 3
Unit 4
Unit 5
No. Street
52025 Avenida Diaz
S.F. Lot # No.
1886 Unit 6
Unit 7
Unit 8
Unit 9
Unit 10
Comments Cert #24195, 24196 and 24197 combined on CC #406657810
IYCI
Q BERMUDA DUNES
RANCHO MIRAGE d
INDIAN WELLS
d� PALM DESERT y
0
LA QUINTA
RINYJ
VV O .Y
773-211-013
La Quinta
0301-158
1
Street S.F.
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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,886 S.F. or $4,036.04 have been paid for 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 CC/Bank of America - Stan Kozloff Check No. 406657810
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by S
Signature
McGilvrey
$4,036.04
Payment Recd Over/Under
NOTICE: Pursuant to Government Code Sermon 66020(d)(irftl—is will serve to notify you that the 9D -day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
M
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is to determine: 1)
that the proposed housing design does not duplicate the same architectural style of any house
within 200 feet of the applicant, and/or 2) if there is a need for .the applicant to file for Master
Design Guidelines. If the applicant does need to file a Master Design Guideline, please transmit
this information to the Building and Safety Department as part of your correction list. Please
attach additional explanations as necessary.
APPLICANT: K C, 'Aue-1 onnn e�
SITE ADDRESS: 6-p- OC2`5 O_Ue Y l d a�-
APN T73_ -al 0 1 3 CASE NO.: �7
a
LEGAL: LOT. BLOCK �� UNIT S.C.@V.L.Q.
CHECK AND APPROVED BY:
DATE:
Inform the assigned Building plan checker -upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track. applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Verify legal and APN information
Consistent with MDG on file (as
applicable)
MDG filing required (5 filings
since 9/3/98)
Architectural variety within 200
feet of the surrounding area:
°
Architectural design features
Approved by: Date Reso
0 Planning Commission —
0 g ity Council
Initials
Case No. ZAoZ'1b7L!
RMO
0 With Conditions
Other Requirements:
Sladden Engilneering
6782 Stanton Ave., Suite A, Buena Park, CA 90621 (714) 523-0952
39-725, Garand Ln., Suite G, Palm Desert, CA 92211 (760) 772-3893
FIELD MEMO,""
x. Project Name Client:
`,. Site Address (cc, -2—
Job
2 -
Job Phone
Fax (714) 523-1369
Fax (760) 772-3895
Date % 6
Job No.
Cis
Y
Work Done
(A N l 5 h (
Test Summary / Footings Inspected
Test
No.
Location
Elev.
Dry
Density
Moist
%
% Relative
Compaction
Ref. Max
pcf
Moist
%
�-� 6'.
%/0,
y07
\L,
alt- 3
11
J
LJ
VU
Comments
Field Tech. Super. or Agent
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to be of service.