0401-108 (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
?.0:3031 113 C36 C42'FT.4 13113f'/2C
Date Signature of Contractor-
OWNER-BUILDER
ontractor
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 FIJNp Policy No. IMM
(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
workeis' 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: I jApplicant j�
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 upoh 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.
{ �•G/
Signature (Owner/A( Date
PERMIT PERMIT#
.BUILDING 443
DATE j(/M , / VALUATION 597594• LOT 19 TRACT SLIK I
JOB SITE
ADDRESS :34- V���'Y.'1�I'i3.f1',DIA2.
APN 774-042-000;
OWNER
CONTRACTOR / DESIGNER / ENGINEER
3.PNES B1 Ap
TARES C. B iCNAP, 3R.
RO: BOX 297
.73-300HUDIM30K IME
PT, AI..lV1 Dre2ERT- CA 92261
P"'DOM CA 92261
(760)777-9572 (119..119 2505
USE OF PERMIT
I'KNO E FAlvETLY lJii1r1 —We
ICK S.F. SIFD, PLS MIT DOFS 1107 INCL U139 BLOCK sa14'ALI, i'001 SPAS.
OR OFJVEWAY APPROA.CH.13 n REDIXEI71{:i:,E FOR IfULTIPLE PLAN
CHI= OF SAX --E PLAN T1YAL.
TRAC' ' CONSTRUCTION 1,604.00 3F
PORCT3fRA`PIO 11:.00 NI'
0ARA,MIC.ARPOR7 446.00 SF
'L".P:,M COS oil, C0113S'. RIJC:1f +id
y,, yFS'.t".1,:1:l
y� p� �t� + �1 MU
1,
fa,(/Y).(�I�Y��N��1.A}�ttr-/�D'yv�nfry�AtiggLt�3i�?.tl�J,jy.7�'3.9,'CA. t jet /5p� �,S p 1,�(��q Q.(♦ (}
4rO /'1ZUCTION FRE { 0 d x'000-418-\%V\I
PT..-" G;1iWX FLS:- 101 -GOO -439-318 $131.64
FRE DEPOSIT 1 1,�• '101.000.439.313 42511.00
I W,HAS'J4X.AL.FGfa _ 101-000-421.000 $65.50
ELECTRW'AL FEE 101.000-420.000 $113.1
PLUMBING FFZ 101-000-419-000 $1391.00
3 :i R(NIG MOTION F ER, - R9191 -D 101-000-241-000 50.74
ORATJ1140 FZZ 1431-000-,423-000 slioa
DEVELOPER IMPACT IFIL $4405.00
PI IP-C,ISZ P LAN 101-000-441-343 $1:30.00
OUS-TOTAL t.''(QMMLICTION AWD PLAN' MW M.
$3,594.94
LESS PR E-11AID IME S
4250.010
:f07M. ]PERMNIXES ]' Y.I'. ES LIE !NOW
$3,344,94
M
kSAN 14 1004 c/
ECEIPT OF
�C % I , 1l
t•Nrq O
BY �
DA E FINALED
�, "7 --
NO
INSPECTION RECORD
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
— l/
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
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 Pibg. 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 I
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
;
Final
COMMENTS:
I
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.
25358
Owner
James Belknap
Address
P O Box 297
City
Palm Desert. Zip 92261
Tract #
BLK 177
Type Single Family Residence
Lot # No. Street
Unit 1 19 53120 Avenida Diaz
Unit 2
Unit 3
Unit 4
Unit 5
CERTIFICATE OF COMPLIANCE �XFIEDSC'
Desert Sands Unified School District��� IR
T
47950 Dune Palms Road
`,� Cq Q BERMUDA DUNES
La Quinta CA 92253 U) RANCHOMIRAGE
b
7 INDIAN WELLSPALM DESE
ti
(760) 771-8515 �t_% LA QUINTAT�yy
.Q INDIO
O
APN # 774-042-006
Jurisdiction- La Quinta
Permit # 0401-108
Study Area
No. of Units 1
S.F. Lot # No. Street S.F.
1604 Unit 6
Unit 7
Unit 8
Unit 9
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 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 1,604 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 I$0.00
$3,432.56 Over/Under
Signature C
NOTICE: Pursuant to Govemment Code Section 66020(d)(1), this will serve 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 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 DistrictCs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
`' 001153.
wSladden Erigineerin.
6782 Stanton Ave., Suite A, Buena Park, CA 90621 (714).523-0952 Fax (714) 523-1369
39-725 Garand1n., Suite G, Palm Desert!! CA 92211 (760) 772-3893 - Fax (760) 772-3895
i T o
is Date
Job No.
11=1 n MEMO
Project Name
Site Address
Job Phone
1-U 0 U f
Client:
Work Done ( `
Test Summary / f=ootings Inspected
Comments
I4 �
Field Tech. Su er. or Agent
R
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to be of service.
Location
�.
4 i
/
M
R=-
Comments
I4 �
Field Tech. Su er. or Agent
R
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to be of service.
Certificate of Occupancy
T4&f 4 44uArw
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: 53-120 AVENIDA DIAZ
Use classification: SFD
Occupancy Group: R3
Owner of Building: JAMES BELKNAP
1d�
Building Off iciaf
Building Permit No 0401-108
Type of Construction: VN . Land Use Zone RC
Address: P.O BOX 297
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date 6-7-04
POST IN A CONSPICUOUS PLACE