0304-191 (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
,203 01111 2A 0305 C33 HT I 18 CY2
DateSignature 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).
T ) 1, as owner of the property, am exclusively contracting' with licensed
contractors to construct the project (Sec. 7044, Business &Professionals
() 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.
(..) 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 S`j:Nf'?* FUYID Policy No. '115116,% S
(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.
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 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 inspect purposes.
Signature (Owner/Agent) y” Date
PERMIT #
BUILDING PERMIT_.;
DATE 7 VALUATION r e LOT r TRACT, + .JOB
SITE.
ADDRESS �L�A s?e�dai<i t�. �iaJl�I�
APN 7!I •eJ� R'il.�
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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JUL 0 9.203 .
9OUINTA
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CITY NDEPT.FIN
<�x I f,
RECEIPT
DATE (
BY,rDA
INAL D
INSPE
a
'.4'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
L PL
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
A2 C)
Compressor
Insulation
p
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
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
, .Q
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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) j1141 d
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 1,604 S.F. or $3,432.56 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/LaJolla Bank - James Belknap, Check No. 306718
Name on the check Telephone 760/777.9572
Funding Resideritial
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Shat MCGilvrey Payment Recd $o.00
$3,432.56 over/under
Signature C
NOTICE: Pursuant to Government 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, %hichever is earlier.
NOTICE: This, Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
i
CERTIFICATE OF COMPLIANCE ��Sc
Desert Sands Unified School District
47950 Dune Palms Road ¢ gERMUDADUNES r"
Date 7/9/03
ms
La Quintaf CA 92253 RANCHO MIRAGE CJ
�. INOIAN WELLS
No. 24679
(760) 771-8515 ���PjA„�ND10 �y
Owner James Belknap
APN # 774-094-007.
Address P O Box 297
Jurisdiction La Quinta
City Palm Desert . Zip 92261
Permit # _ 0304-193
Tract # BLK214
Study Area
Type Single Family Residence
No. of Units 1
Lot # No. Street
S.F. Lot # No. Street S.F.
Unit 1 18 '. '53370 Avenida Villa
1604 Unit 6
Unit'2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments Certs #24679 through 24682 used for CC#306718 in the amount of $13,730.24.
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, 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 1,604 S.F. or $3,432.56 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/LaJolla Bank - James Belknap, Check No. 306718
Name on the check Telephone 760/777.9572
Funding Resideritial
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Shat MCGilvrey Payment Recd $o.00
$3,432.56 over/under
Signature C
NOTICE: Pursuant to Government 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, %hichever is earlier.
NOTICE: This, Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
i