9510-005 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm Viat 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 # Ai' 07 % Cf 4 5 Lic. Class ,r,°`' Exp: Date
Date 97T,—Y4 Signatureof Contractor
OWNER-BUILDER DECLARATION
I hereby affirm 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.
(,eK 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 issuA'8a`W4brkers' compensation insurance c&.ri9K&,`'policy no. are:
Carrier . Policy No.
(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 workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. y
Date: 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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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) +¢ r't r1101,11�, Date
ALO0
BUILDING PERMIT
PERMIT#9510dx)5
DATE!; �1ttIK
VALUATION(SLOT
Ing TRACT
1�f
JOB SITE ADDRESS
APN
. 7.150 VIA C VIK1'1l
(43-1004)42
OWNER
CONTRACTOR
LANDAU DE v'E1.VIxbIEN'I
IMI'ii IAL SUR,`' CONSTRU-MI }N
al7.210 VIA OVIM)
2825'l'A140l.ifrZ 'A,NY0N #01
PAIAI'%PRIN(if� ('A 01261
!�1�+RIN
PAT.11A1ry
('A W2261
0�iS
S'T'A .ft'
Y
.'i-fOhhtl
DESIGNER/ENGINEER
IiJ002-1Ja11
USE OF PERMIT qf'f )
LP%Y"E LA LUtN'i'&
`IM-4,Ill 00CIS NOT INCLUDE' 11LO �(, K WtULI,S OR T' lf)L.
FEE DESCRIPTION
FEES
,PI AN (21°Lt. C K DH'P0SJT
4TWOO
IMAN ('1110TIK F11F F11
jilt M0.4314-119
572() if)
C0NS'I KU1,''!I1(; ITA
1011000. 1 AIIS-000
MECHANICAL FIiF
101 -000 -421 -OW
I021,
ELE' IRICAL FEE
101.-000-420-0110
$176.45
PIXM1411ING 11.111
IOA iii
STt�NU 11.11(117101-4, FEE — RESID
10() OW 2 U 000
X15 �f
GRADING FF.£
101-000.4213-000
$20.00
1NFRA.S'i" 1.1-I'' IA.}t FER
225-(X* 43.342
$3,454.11
ART IN P1111141,10 PI A('PS - .1h Sll
704401-75-5-000
$1.1339
it
d
,
l
OCT
41995
By-
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
jp
Underground Ducts
Forms & Footings
Ducts
Slab Grade
p {
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing /
Compressor
Insulation
t
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
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
p / 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) I
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 U
Utility Notice (Perm)`
COMMENTS:
1 fi
DESERT SANDS UNIFIED SCHOOL DISTRICT
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
Date 10/3/95 1 Type of Permit La Quinta
No. 13736 Permit #
y _ Log
Owner Name Landau - Development
No. 47150 Street Via Ovieto
City La .Quinta _ ', "Zip 92253 Study Area 123
APN # 643-160-042 Tract # 26152 Lot #= , Square Footage 12583
Type of Development Single Family Residence No. of units 0
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 1.72 x 2 583 or $ 4,442.76 have been paid to D.S.U.S.D. 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 Imperial Sun Construction, Inc.TeY pho�?e`",328'2277
Name on the check `C tiK
:
By Dolores A. Ballesteros ttti r.,
Superintendent ilk 1z)
Fee collected /exempted by Pauline Pearson '
Payment Received ,
Signature (o� u o „„ Q 1 A A A V\ $4,442.76 Check `No. 14172
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