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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
Signature of Contractor „ _
OWNER -BUILDER DECLARATION
V 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).
'( ) 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
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:
Carver WfA.TE F'UI313 Policy No. 58413DRO
(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,;lxsh 811 forthwith comply with those pro6ions'.°) 1
Dale:Applicant
Warn ing: t ( Fa ure 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.
;o'
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 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),F', Date 9
- BUILDING PERMIT PERMIT#
DATE VALUATION LOT W01 -1w TRACT
> S1,11,333,40 3 5
'DIX
JOB SITE p
ADDRESS ,0,V AVFJJ A
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
11
1XIC r)EVEWPIAENT
xc. m. vM,oPMWr
$0.1.45 VISTA GRANDE
80.143 IMA GRANDE �•
LA ,} MaA CA 92253
TA, QMTA rA. 92253
(760)578.0325 ("3AA
USE OF PERMIT
14GIF FAM L Y DWlwE ING
18&5 S,F Blvd. P'VZ fA),T DONS 'NOT I'I If°I: 0DIt HLOCK WA; %, 1" COI,' OR
DrdViW YA IPROACH, 73%REDUCED PW4 CHECK FE I+OR%IWAIPLr,
P1.A'tdS OF SAME TYPE
TRACT CONSTRUCTION I'm, Do JF`
PORCWPATIO . 32.00 SF
0ARAO& ARPORT 42.0,00 pis
l:D COW O coli rRU ON
:111,33 3,40
y�py +�•a y(y� a q ��.STEVIA1
PERM t.&+ F BS. , S V dV :7,16,1,4. i
t t NSTR1.IC'e ION FEE E 101.000418.000 Sol.$#
PLAN CHZC.K IFEE 101-000.439-318 $141:02
FEE UEPOSIT 101.000.439-318 4=00
MKCH NXICAiI. rJ?.R. 101.000.421-000 $59.OU
iL'RO' Rit"::1Ie 601.000.421.000 $122:Qf
PlItfmSlwoMZ 101-000-419-000 l 3,
011TR:CaNOMOTION F"', • USID 101-000-2A.1-000 $11,12
ORAD1140 ):EE ,101 -000-4M -OGO 05.0
DEVELOPER IMPACT .KEE A405,00
PRECISE .?I—bal 101 �t3t)0 469,1 3�S $1001011
01.x='�C3�'.�T;CO � t Z:k:T�7IQ�SA2�9 k�.Ata CHR
1
UL)
1,01 1,01§1 1pt21.-PATL FEE?
13,660.61.
..VZ50,f it
__1
p� nn r k l iP�flT k� hs��)1IF I��Ji'$3,410AI
CITY OF LA QUINTA
FINANCE DEPT.
_.r --•-La— OG
RECEIPT
DATE/
BYo„
JDATEFINALED
NSPEC
)�/7
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
—Q.
Ducts
Slab Grade
O
Return Air
Steel
l/
Combustion Air
Roof Deck
-
Exhaust Fans
O.K. to Wrap
15;11:, ?
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%r0
Drywall - Int. Lath
Final
Final — O
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
Water Piping
_
Heater Final
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�Y
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�3 yj
Final
Utility Notice (Perm) - - &4! Q
COMMENTS:
i
p3ol - /Sq
Building
AddressJnVC.�+I 5?—)% /��)� p I Q4
Titivl
"
P.O. BOX 1504
Q 78-495 CALLE TAMPICO
fl1—ILA QUINTA, CALIFORNIA 92253
Contractor Av I IC::-- A a
ress
Zip
State Lic.City
& Classif. '97, IIE3ft' 5 0 Lic. #
Arch., Engr., ,�
Designer 7419
Address — A , r ti d el.
City IZip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to 'its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (8500).
I", 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds -improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I I I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
Cl Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with Such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
1 certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant —Date—
Mailing
ateMailing Address
City, State, Zip
APPLICATION ONLY
ILDING: TYPE'CONST. OCC. GRP.
'. Number / I % -]] ,,/��'—/�®1 _
cal Description te� 3, A�®K
Iject Description S F p
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ dd ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
ZS77
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.---�e._.i
Grading
Driveway Enc.
Infrastructure
JAN U J I.01J3 IL)
rf�1i flF G ►Ci aI*SSA N
FINANCEJ1 ,, --r I_---=
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE
Comments Cert #24195, 24196 and 24197 combined on CC #406657810
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 Irving, 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 $2.14X 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 /exempt by Sharou McGilvrey $4,036.04 0.00
Payment Recd Over/Under
Signature //l/fAC2,1�
NOTICE: Pursuant to Government Code Section 66020(d)(1), ks will erve to notify you that the 90 -day approval period in which you may protest the fees or
other payment identified above Will begin to run from the date on Whieb 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 DepartmentlApplicant Copy - Applicant/Receipt Copy - Accounting
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: 4�C "IWd U Yne- ±
SITE ADDRESS: 61-P - t)35 Ne - t d z —,D � a2.
APN %? 1- 1 - 01 14 CASE NO.: %(o 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
A
Pi
oved b : DEQ Reso #
y Council� mmunity Dev. Dept, o ��
"c*
ase
xhi
No. _MZ -102-
it
Other Requirements:
Wi
h Conditions