9807-178 (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 vode, and my License is in full force and effect.
License # � Lic. Class Exp. Date
Date t', jl k( 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 BARIC. 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 ante 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.
UM(:AUs INS CO 179
(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 tothe workers' compensation provisions of Section 3700 of the Labor
Code,.I shall. fort ,with comply with'those pro4isi Q
Date:rJrr-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 can
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 inspe1ctiion;urposes. ,
Signature (Owner/Agent)' ' • v� b Date ��
PERMIT CONTROL# .
BUILDING PERMIT. .
9�t} 47fr
DATE VALUATION LOT. // TRACT m� 5�,2�i,70 g3 f dw
JOB SITE d
ADDRESS $7-y OPE
APN
643-14,11-4.30OWNER
CONTRACTOR/DESIGNER/ENGINEER
:"�,�t�A'�3�'Yc�;CC�.9'�'.����!
C.ANIA1'.).,VY`�CJ.�1�P NY.
1570 MOOK.'t OL =w—, Si7_tir 208
1570 8R(3C: K -,t0 LLO , t).i [VE, 9Uf11208
.LOW
SAA M .ANA CA 92705
S.WYA ANA CA 92705
l.t.tt 7h, -9is5 (:131:,x,? X40; 5.
USE OF PERMIT
7
; ii�ri Lta;3� `1itLY i� rRILUNG.
r
8FD -PLAN AN 300. G - Pt.t2KIT bO S iNirsT WCI,`t.iDE :BLC CIRI WALL OR
POOL. t�td C°►l� c;is' i'�iE �Ci?OLIC !~i7 75F✓P 1'C)tt A/ill.1: ['ll'J.l� 15�;1JANC !, OF
#L
t ,
TRACT CYY S'1Z:UCI'1014 2,39I,00. Sl
K)RC.Fffl''.ea.'C.10 =dit.(i@ 5F' .•
°
0ARAGEtC:llf+:K)Wr G tIi.ENI SIF
.'�rllA ���' €9. C® �i 'i: � 71�°e✓i1
1 531V05.70
CONSTRUCTION Fh-E . .1.01 -13W -418-01D0
PLAN C3 _ CK 1ZFE 101. 0004139-318 S174.40
I ` w1 C 13 ti3Sl1° 101.000439�-31II
MECa4AMr','rV:.F IC7i=001-'2.t>UOU 5 :
.LLEMR.ICAL 170F, i0d 00 4x0.004 135: 9
P►U 17•fC1MT )04.(:)01419>0) 1160.t'q}
S rZ0,NC31+4Uf10.4 i:•hX RES11> 1034C0-241-000 $15.33
ORADIN t F 101;000-4.23-M
RNFRAS riz lr CTUR kFk 225-000443A
m' 134 PUBLIC PLA .CES -12. sm, 701-W_0425 -000 5133 dl.
SUB-TCYC'.A1.,CONS" RUCTION AND PLAN -CHECK
-LSSS t•' 41 AID IEESS
4250,00
TOTIV, PEWIT DUE N"01V
54.776S9
RECEIPT
DATE
F.
BY
4i
IAI
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
S' _
Underground Ducts
Ducts
Slab Grade
—Z— /
Return Air
Steel
Combustion Air
Roof Deck
�—
Exhaust Fans
O.K. to Wrap
Framing
n
- `" L
F.A.U.
Compressor
Insulation
- (S = S (
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—( -F f
Final �j-' _ l
BLOCKWALL APPROVALS
Final
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
�
Heater Final
Water Piping
/ %
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
(�_� 7 �/
Encapsulation
Gas Piping
Gas Test_ds�
_
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
1
Final
Cltility Notice (Perm)
COMMENTS:
S'h.,i ' � e�;c"' i:+i �I.^i1`�y.�.r:t�r � 1 > „+ 's�+''.`""C,.•:yWtw .'- "".� ^7"='aF�7»+"Y�ieT,�,'•�Y.�rY�'`w>L
0 T4'yl 4 4 Q"
P.O. BOX 1504 APPLICATION ONLY
Building 4760 Oio
_0 78-495 CALLE TAMPICO
Address LA QUINTA, CALIFORNIA 92253
Owner /1 t n
CN (.Ci .
Mailing
Address f S70 6Wt 10J to
City Zip Tel.
Contractor
Address
State Ljc. �n { j / ' I City
8 Classif. `-'� ! b Lic. qj
Arch., esg`L.Pki �6�p1 Co,
add ess Tel.
t G� 16dC �c
.0ity ip State
LICENSED,CONTRACTOR'S DECLARATION
I hereby affirm that I�m lir,/eneed }finder provl`7oLls of Chapter 9 (commen ng with S l
7000) of Division 3 01 he B sin ss•a Proftession Code, and my I`cepse s 'n f II for e�
effect. /� /llif /�M I I / k'i
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors Licen a 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 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for thealleged 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.'. 1, 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.)
Fl 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.)
I 7 I am exempt under. Sec. - B. & P.C. for this reason
Date Owner '
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a cenificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. ❑ 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 (8100) 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, 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.
Ca
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 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 stale 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 a0plicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number
Legal Description , _f
Sq. Ft. No. No. Dw.
Size ,, Stories Units
Add ❑ Alter ❑ Repair ❑ Demolition ❑
PERMIT AMOUNT
Plan Chk. Dep. Z
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
•_� Rear Setback from Rear Prop. Line
L I
Side•Street Setback from Center Line
Side Setback from Property Line
AUL 44 ►999
FINAL DATE INSPECTOR
`� r — -
ed by:Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Notice:
Document Cannot Be Duplicated
Date 6/28/99
No. 18949 .
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Jurisdiction
APN # .643-140-033
643-140-004
Owner NameCanaday & Company Permit #
No. 47-940 Street Via Opera Log #
City La Quinta Zip 92253 Study Area
Tract # 26152 Lot # 89 Square Footage 2,591
Type of Development Single Family Residence . No. of Units 1
Comments
,ake La Quinta(Tract
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 t --in tl eIii&un'tof,
1.93 X 2,591 or $ 5,000.63 the property listed above and that building 4«=
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
.., , r
Fees Paid By cc/CA State Bank/Lake La Quinta Communities T'e'lephone ?,,71-636
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $5,000.63
Check No. 51152
Signature jJ
NOTICE: Pursuant of Assamy 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 0istrict(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 _