9807-187 (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 •
ymioo
Date !Signature of Contractor`s
i
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).
O 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.
(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 Policy No.
UNICNIZE,N'S CO SC50-1197-:1.4179 .
(This.section need not be completed if the permit valuation is for $100.00 or less).
(j (.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,provisiofs o Section 3700 of the Labor
Code, I shalltf rthwith comply with those provlst• n . r
Date: a? /�r�� 1 `/ Applicant .M.�
/
Warning: Failure to secure Workers' 'Cor npensafion 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 td the building
construction, and hereby authorize representatives of this City'to enter upon
the'above-mentioned property for�'in`spect! n pur oses.
Signature (Owner/Agent)--•-�'�'•��`r Date `~ 117�
,{ -
PERM';# °°NTfi°`# .
a BUILDING PERMIT x.57
rIl17
DATE VALUATION S 150,874 LOT �q TRACT ` i
^�� 7 7
'
JOB SITE
ADDRESS 47475 VU O.PtRA
AIN i
643-141(W39
OWNER
CONTRACTOR
/j^DESIGNER / ENGINEER
AAq ♦� S1 e y j
11ik N'AD.I-k 4b 4s{�%•O�R��ANY •
p
a.•di•i�1L'�1.11�..1. ti ' riC.,�C1ai�:�r'•,..NTY
1570 Biit` OKROLLOWDIUVE, SE1I VE 2a'
1570 13ROi7,KHO:Lt OW 'Did' SU11".E 08
SJWfA 14.1<iA CA 92705
,
SA.N 1 A -ANA CA 92 705
f7l4 iSl-gl Si: C.81.# 4485
USE OF PERMIT
s
SFO, P1 AXAM P. :MIT i0t714 NOT INCLUDE MOCK WU OR Vom. •
f�C,Ai�! i ki l LE F2k't31 fG tJ t ° i FOR MUI, i -PLESWAN L, OF SWlftilE
PLAA' `F' PE.
�t`;<t� GcNS C a °M507.00 ��
`
1�4�I�4 11/1�ti l'IlJ FB'') 00'53
Cf•ARAGEIC;ATik'OR'F''
1101
411CIINSTRUCrIONF"t E J01-000-41.8••000 SSIS,00
3?i,AN CHECK11 .F. 101-000-4,39-3IIS
101L,0A0-439-R3 8
Ii FC'€l`ti.ivi[GF�.:i:.b'P.)3 1�1=eD�-42i-QO(i �I05.04
,FOMCAL FEE
PF:t.MBINGYM. :1-01.n00-43.9-000 $1�253:t
M"•RONG'NIO'I JDN FEL - iW,8]D 101- (110-241.000 $1-` 09
1t :C7t'tvcx 101 -OW -42.3-000 gal..00
INF RAS; Y(LIC CURE M. 'l—y"00-44:3-342 ..
ART YN f'I)B1,j:C P:(.ACE3 - RESir 101-000-255,Q00
U'1 '(7TA1�.t� N '➢ i?C"1 0� ANDTLAN CHECK
S4„9312.33
LESS Pl.E-1)AID .t EES
4,250.010
TOTAL PERMI N-IMENOW
$4,691.355
RECEIPT
DATE
BY
D A E%
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
8 �6 e �7
Underground Ducts
Ducts
Slab Grade
8 �S /� C! 5 -Z
Return Air
Steel
f
,Combustion Air
Roof Deck
�'=02 7
Exhaust Fans
O.IC to Wrap
_ fp -SY
F.A.U.
Framing
r1 " / ,—STCompressor
Insulation
/ _ g 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
(- ZZ -
Drywall - Int. Lath
IV 91 f
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
I
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
/O -a7 T
Encapsulation
Gas Piping
Gas Test�^e, �p
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
t -
r.. J
Final
Utility Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 6/28/99 APN # 643-140-039
No. 18955 Jurisdiction 643-140-004
Owner. NameCanaday & Company Permit #
No. 47-875 Street Via Opera Log #
City La Quinta zip 92253 Study Area.
Tract # 26152 Lot # 95 Square Footage 2,507
Type of Development Single Family Residence No. of Units 1
Comments
e La Quinta.(Tract 26152)
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 or replacement mobilehomes.
It has been determined 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 Government Code 53080 in the amount of
1.93 X 2,50.7 or $ 4,838.51 the property listed above and'that building 0
permits and/or Certificates of Occupancy for this square footage in this proposed project ay nmy,' issued
Fees Paid By cc/CA State Bank/Lake La Quinta Communities >rei�phone, ;771 _9636 r "f
Name on the check'
By Dr. Doris Wilson I t:
Superintendent
Fee collected /exempted by . Juanita Green Payment Received $4,838.51
A D Check No. 51152
Signature
NOTICE: Pursuant of Assi1mbly Bill 3081 (CHAP 549, STATS. 1996) 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 sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the Districl('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy -Accounting
.,,;rye` i'r"-y..*'wf...t?«.r��-yss2.;•�-�'*k-.-.r.:�.. ..,;rr•r.Y- "Thr_.t44.v+f^.•,�,..:{�+"'�`,t`�i�'A.�,+"'�'�!�,..':rsv�Ti.^``:r•.�,.r+t""`'r,i�:,�1�1.r.��, ir'i1'i'1�atJ".+�.kiiaT Mr'��yn��k>�^�.
Building 1-f 7VS� V ��
Address y / �J
Owner
(Vt,yi n A w cit, (Q .
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Mailing , `��� 1✓V�.'� �� I
Address
Contractor ,� I
Address \
State Lic Cit
& Cla sif. 5 11 SCJ I I Licy# Ql.je
to �
_71T
City Zip r State
�J�� 1tf\lam ��r� Lic.#
LENSED CONTRACTOR'S DECLARATION
I hereby affirm tha rl am,%ensed�under provisions of Chapter 9 (cc
7000) of Dlvisfon 3,ij the usi temId d Profe Bions Code, and my li<
effect. /� / _
/ 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 or 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).
l.,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 or 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.)
17 I 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. 3900, Labor Code.)
Policy No. Company
n Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars (5100) valuation
or less.)
I certify that in the performance of thg 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 or 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
.I hereby 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
ame
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.
I 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 sof this city to enter the above.
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
P. Number
Legal Description
Project Description
1 0-1t?T�- ki !a ODOCO .
Sq. Ft. No. No. Dw.
Size Stories Units
Add 0 Alter O Repair ❑ Demolition O
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
O
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
(S de'Setbba from Property Line
FINAL DATE INSPECTOR
Issued by: JUL 213 leD tae Permit
Validatedby:',.."
Validation: '
WHITE o FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION