9807-189 (SFD)LICENSED CONTRACTOR DECLARATION
!,-hereby affirm under penalty of perjury that I am licensed under provisions of
,ihapter 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
5(71.56. 13 f1/00
Date'' 1 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). y
() 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:
O 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
perfor'ance 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 Policy No..
U1viCAk!:1 INS Ca
(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 wo�kers' compensationaprovisionsp f Section 3700 of the Labor
Code, I shall forth, comply with tliose,provlsl�lrs.
Date: /l t%//Applicant
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 enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �j`-' "�'� Date
' WO NG PERMIT PERM';;CONTROL#
DATE VALUATION @@ i ! I''gyp LOTTRACT { /a��
fa.?ligi9:&� J-676
Y0
JOB SITE
ADDRESS �l 741 V1A 0PK9A
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
..(/''� pp Ri 71, �C+' SLC * •l', pTL'
�1 A p M Y j1. F+�'y� IP Y
4.r.&'�dV li.iJ'.�-4 L i.-�. 4�./.��.Rb. N�d {, .
1570'8K.C143KHOLLO W 0iCiVE, .�Ul' T 20
0,70 BRO(Y1ti:i iOLLCiW":DRIVE, SVIMF 208
SANIA ANA. C;A. '92,705
SAYNk jkNI A Cts; W705
�34)75I�gi5t, (;131.:9 4485
fl
USE OF PERMIT
SFI3 _ 9f,AN' alta .. PRR&5TF' DOES NOT 1W^i.%3D O:OCk WALL OR POGE..
IPLAN CMC -9 f, BE REDLfM 7S?14 ,FbR Ad -1131:V.0 1&SUANCi`f1, 0F SMAIR,
r
PORC.�iIPA'! I s 17 9,00 S�
C" iARakG6/CAPf1t;YRT Zi -,4.00 3F
ai
:P gX4WfT Frim sumMARY
LOl+fs.'MUCTH'�7XFFE 10J."418-000'
.PtAx cnecxMll '101-000-4 19-318
' 6' •f QAL f'1"�8 101,-000421.000 S1,015-00
E,L1wd:'iWCAL:t l . 1U,1=01 - . 0y{?OCl _ S1m.-I-a:
'
I'I,l xr 31NG k`F;i;, 1. 1-r.�t3f%- .i9-(1(}tl 2f 50
STRONG 'iox 1: Lf3 - 3wESID 401 -000 -24:1 -MO
MR DINO O F 101-000-4 -CtN) $20.tx1
INsN;RASI UrrTURE RE 225-000-441-342 $3.1AX11
A1<'I.11003LICPLAC"ES-1ESlD70.1-000-255,000 S1.2?..t9
5S1B-'1OTr'!, GON_',MUCTIOU :kND PLAIN CHECK
�d�,g��?•`z 5
1,ERR'S fi?}tE.PAID F#. -ES
4250..00
C3 i til, �'l t? ;1�.'► D J1; I�ow
RECEIPT
DATE
BYE
�j\
INSPECTOR
r
INSPECTION RECORD
OPERATION .
DATE
INSPECTOR
OPERATION DATE INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Q
. t
S
Underground Ducts
Ducts
Slab Grade
-Z-
Approval to Cover
Return Air
Steel
Equipment Location
Combustion Air
Roof Deck
Q _ to -
Exhaust Fans
O.K. to Wrap
Framing
/t!
_
F.A.U.
Compressor
Insulation
Gas Test
Electric Final
Waste Lines
Water Piping
Vents
Fireplace P.L.
Plumbing Top Out
Grills
Fireplace T.O.
O.K. for Finish Plaster
Fans & Controls
Party Wall Insulation
Pool Cover
Sewer Connection
Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
1 .
COMMENTS:
I Final
Umrty rvotice tuas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Ublityy Notice (Perm)
Final
Final _ �:Z7-02 I j�g
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
L /p _
/ �(� S?
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
COMMENTS:
I Final
Umrty rvotice tuas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Ublityy Notice (Perm)
'":� �; uv �T t�+�a `7" .-: �.a i,,.., v, P, r..� ,+titer #.. v-', �"""Yx+` `-v4 � lir"" +�,• n•.rtw•J y- rS,.� 4 . -v.� • r'v.rw. r,.1... .:"') r . .- r,,
u�flrGv l
BOX 1504 APPLICATION ONLY
Building"""� 7� f
� 78-495 CALLE TAMPICO
Address t1-7 9 / V `� (� oP \ a— LA QUINTA, CALIFORNIA 92253
Mailing
Address
AtY 11G � Zip..1/)"70 I"- 7SY /)
Contractor
State Lic. City ��
8 Classif. ��? Lic.
Arch. Eigr.,,_p�
ed s gne
7 V\•
i \ 1 ^J State
�kar•i" Lic. #
LI ENSJD CONTRACTOR'S DECLARATION
Irm that I am tcenspd ynder�grovislons of Chapter 9 (commencin with S ctlggm
Sion Sof She usfes end Pr.P Mons Code, and my licences mull fo gfid,
OWNER -BUILDER DECLARATION I 7
I hereby affirm that.1 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 th
Division 3 of e Business and Professions Code, ov 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 ($500).
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 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.)
" 1, 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.)
i7'I am, exempt under Sec. B. 8 P.C. for, this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, ora certified copy thereof. (Sec. 3800, Labor Code.)
Policy Nb. Company
❑ 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 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 it
Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after 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
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 -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant -Date-
Mailing
ateMailing. Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number
Legal Description t '10
Project Description
Ufa
/��
v'Y /I)o lima [JirlP( q,
TOTAL - I I
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
INSPECTOR
�. ti'J 0,48
Issued by: Date Permit
Validated.by -
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Sq. Ft. 507 No.
Size Stories
No. Dw.
Units
Ne Add ❑ Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL - I I
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
INSPECTOR
�. ti'J 0,48
Issued by: Date Permit
Validated.by -
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 6/28/99
No. 18950 Jurisdiction
Owner NameCanaday & Company
No. 47-910 Street Via Opera
City La Quinta zip 92253
APN # 643-140-034
643-140-004
Permit #
Log #
Study Area
Tract # 26152 Lot # 90 Square Footage 2,507
Type of Development Single Family Residence No. of Units 1
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 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 2,507 or $ 4,838.51 the property listed above and that builanngr't'A
permits and/or Certificates of Occupancy for this square footage in 'this proposed project maynow ,tie issued
Fees Paid By cc/CA State Bank/Lake La Quinta Communities TOapfione -?71-9036 u
f a
Name on the check. 'k
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $4,838.51
Check No. 51152
Signature
NOTICE: Pursuant of Assdfnbly 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 District('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