0208-146 (AR)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
Q ,p+57 1i ��: 1 � .P t731:31�f26
Date 74A71- Signature of Contractor�a'KS�-
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 maintairi 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�j
Carrier IWOalTed k ry :i?j7kL"Y� i !s Policy No. ?*00040-1 ns"
(Thjs,section need not be completed if the permit valuation is for $100.00 or', I ss).
(`) I certify that in the performance of the work for which this permits, issued; a
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 r6ecome•1 `
subject to he workers' compensar ionlprovisions of Secti n 3700 of the Labor
Cod sn II forthwith comply wi,h the 6ro6ions.
Date',
��� Applicant`��"J
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 370.6
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on; his
� application. t
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to j
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void If
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby :authorize representatives of this City to enter upon
the above-mentioned property,forjn vection purposes.
Signature (Owner/Agent)L*--ti-x Date +
PERMIT #
BUILDING PERMIT
,
DATE VALUATION LOT TRACT
r
JOB SITE =
ADDRESS 79-94.15- DOUBU XAGLF
APN
7 715-250- h 6
OWNER
CONTRACTOR/DESIGNER/EN (NEER
DrO C7:. 11:03
)3(`JBhV%VtAk.D8CO�a�MRi:tl�"ROW
79-945DOLdBM."C.M XaE
79-9201IRSIT'A:fiRIVB
J:A QUD -A. CA 912.25?
LA QUVRM CA 922S3
`160)175-79"3 �BV0 32112
L
USE OF PERMIT
I Jfi AY.. +� ieJ AD-DraCX_
f ! EISITUVINCED COST OF CION 'I 1 IJt:�* ON
4.1,442,80
CS3NOWUCTIc�N FEE 101.000 -AIS -0093
T�gg.�ggF{�e;;1+1 -!�?¢7�p��^��pll��SSJ-�+�p�y�•$, ��Z�?/t,pd�
k{{�E�����qq'pp
qq yyECX
y91tAi]�
5YYiY5J6�Ft•�IICA1d FEE !V.6.°lJ4%ii"'�l'24i°000 $'40. 0
ELrC'c R'Xt .AL ",X 101 -00102•20-000 SSz. 11
�.
PLUMBING :PUT 101.000.419,=000 M3160
M'E2ONQ MOTION ME, - IZE91D 101-G- O? 241-000
J�
a»
.�sG V-°Ft314� ', at�;s�`1t.LiC°f'lty1+� iah MAW&�ffK.
�istalti.4i3
.SEP 4 5 2002 ;`9TAL DVENCM
st
CffYAFLAQUINTA
FINANCEDEPT.
a
RECEIPT
DATE
111t, (� •, a
BY ,, r +
F..I
DAT FINA D
INSP T R
fJ�,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel j
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents. .
Fireplace P.L.
Grills.
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final 4
Final /
BLOCKWALL APPROVAL9
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 !/f//�
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
Final
Utility Notice (Perm)
COMMENTS:
Comments
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 532 S.F. or $1,138.48 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/1st Bank - Donna Ricketson Check No. 63058
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green $1,138.48
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Govern ent 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 District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
Bin #
City ofLaQuinta
Building 8z Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
008 -lib
Project Address:
Owner's Name: �— " (�j f—C �s C(-Augij
A. P. Number: I 15 —,215 0 ex) (0
Address:* -74) g 4� 'Uo M CE
Legal Description:City.
Lff%
Contractor:
ST. Zip: �
Telephone:
Address:
Project Description:
Cit -,. ST. Zip: *-t4rXJ("
Telephone:
. ....... ....
............................
...... .... ........
.. . . ..... . .. . . . .............. . .
-.1 .. ..... . . .... :.X.X,
. . 1. .. .. ..... 1.
-- 7 T& -T—
State Lic. #: tD 8
Citv Lic. #: .3-2112
Arch., Engr.egq—n�.ii?�-
Address:
Cit},. ST. Zip:
Telephone: 74Z oecs;e
..... ... ...
... ........ ...
Construction TN pe: Occupancy:
State Lic. #:
roject
P ' type (circle one): Ne%% Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:. -,k 53
Stories: —F4
Units:
Telephone # of Contact Person: -
1 Estimated Value of Pro.iect:
APPLICANT: DO NOT WRITE BELOW THIS LINE,
il
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
IM Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees