0401-106 (SFD)61
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
205031 A C36 C42 .H1 11/3012(
,/Date /` ' 2 r/ Signature of Contractor �)
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).
( ) 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:
Carrier STATE FUND Policy No. 1376783
(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 those provisions.
Date: 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, 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 enterupon
the above-mentioned property for inspection purposes.
/Signature (Owner/Agent) �/'--�✓ Date / �'' ;'t
BUILDING PERMIT PERMIT#
0401-106
DATE 0,/t/,� o(: VALUATION $97,394.90 LOT 21 TRACT AIK 177
JOB SITE
ADDRESS :1,��ll�� � fL� � Di� J)J
APN ?74-4124104
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JAI REII"AP•
1AML9 C. BELT NAP, I&
P.O. BOX 297
73-300.F1I'R3i.F..AFZX LME
PA'L,M ItiZIERi CA 92261
PATMDESERT CA. 92261
(760)777.9572 CBJ_4 29115
USE OF PERMIT
�3 OtLE FAM:FLY 1.3WRIKCY
16!54 S.F. -.n), PERMIT DOES NOT INCT,: UDE BI,O X WALI, PDOUSPPa
OR TDM'YWAY,APP ROAiCIi.751Yo RLOLTCKD FEE FOR MULTIPLE PIAN CHECK
Ole S.AMIp PLAN TYPE.
TRACT CONSTRUCTION 1.04.00 8F
PORCI°I/Pey,TIO 1 .7,00 SF
0ARA0FJCAAPORT 446.00 SI;
:I3:&MAYEID COSH' OF COD'eS14RCT C3N
97,394-90 .
F9R1Pl 17'.F=1 "'i MMAR1i
CON'TrRUCTION FEF 101-000418-000 x4:10.50
PLAN CHECK FER 101-,000-439-318 $326.Y7
FRE, DEPOSIT 101-000.439.316
MUCt]A3dICR1, i*I;:L 141 _f;0(j.21.000
ZL Ci.ttft` AL FEE 101.000-420.000
PLUINISIATO FEL 101-000-4.19-000
STRONG MOTION FEE - RE -BID ':01.000.241.000 £1,74
f;1KA D.IWO FZ9 101-0004 23 -000 $15.00
.DEVELOPER IMPACT FEE $I, 05100
PidRCISE PLAN 101-000-441-345 $100.00
C0N3TRTJaf10X �M) PLAU C .<CK
1 k P,W-PAWFYYS
3,989.87
-$150.00
O�:'AL'PX1,ZI�TFIEE'S-T)UNNOW
4
jFINANCE
X1;7339.37
1004
LA QUINTA
DEPT.
RECEIPT
DATE /
BY
DTE FINALED
INSPECT
M
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
— A_o;ZjL
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
v
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
POOLS - SPAS
BLOCKWALL
APPROVALS
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
VV,
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Qv
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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) -
Date 1/14/04
No. 25359
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
(760) 771-8515
4���1FIEDSC�o
Q BERMUDA DUNES
rn RANCHO MIRAGE
�J INDIAN WELLS
V' PALM DESERT ,y
IAQUINTA 4
Q INDIO y✓
0
Owner
James Belknap
APN #
774-042-004
Address
P O Box 297
Jurisdiction
La Quinta
City
Palm Desert Zip 92261
Permit #
0401-106
Tract #
BLK 177
Study Area
Type
Single Family Residence
No. of Units
1
Lot # . No. Street
S.F.
Lot # No.
Street S.F.
Unit 1' 21
53080 Avenida Diaz
1604 Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments Certs #25357 through 25359 used for CC#307935 in the amount of $10,297.68.
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered pabos/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 1,604 S.F. or $3,432.56 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/LaJolla Bank - James Belknap Check No. 307935
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey Payment Recd
$3,432.56 Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the gUay 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 Districtfs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
Certificate of Occupancy
TWit 4 4Q"
Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building.
construction and/or use.
BUILDING ADDRESS- 53-080 AVENIDA DIAZ
Use classification: SFQ Building Permit No 0401-106
Occupancy Group: R3 Type of Construction: VN Land Use Zone RC
Owner of Building: JAMES BELKNAP Address: P.O BOX 297,
City, ST, ZIP- LA QUINTA CA 92253
By: KIRK KIRKLAND
Date 6-7-04
Building Officfal
POST IN A CONSPICUOUS PLACE
'153
-(*Sladden frigine'eringil.
6782 Stanton Ave., Suite A, Buena Park, CA 90621, (714).523-0962 Fax (714).523-1369
39-725 Garand-In., Suite G, PaIrn"Desert, CA92211' (760) 772-303 Fax (760) 772-3895
Date A
Job No.,,,.
FIELD MEMO,
Project Name *--Duev Client:
Site
f
Job Phone
Work Done
Test Summary Foptings Inspected
Comments
i.
Field Tech. 0 er. or Agent
1
Location
oil V.,
Eff MM
in
MINIM
mlim"
USE
MIIM�MCOMIM
010�
M�R=
NO
Comments
i.
Field Tech. 0 er. or Agent
1