0108-177 (AR)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 A Exp. Date
7*2A47 d}.S.?Cl.W ,2,P
Date >{� "'Signature of Contractor !?.-,�. /tai
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,.contir' ting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). r" , ,- ,
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.
,.(.;;) 1 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.
111TATEF6.iND 19 5•f�4!t
(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 provgsiops of Section 3700 of the Labor
Code, I shall forthwith comply with. tho ,'6rovlslons
Date 9f.,:.. _ Applicant /,4—
Warning: Failure to secure Workers Cion coverage is unlawful and
shall subject an employer to criminal peompsnalties 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 i
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 i• spectlon purposes.
Signature (Owner/Agent) �� kms-- '" Date f
BUILDING PERMIT PERMIT#
i•,
DATEaf' VALUATION LOTj+�., i TRACT
!
JOB SITE
APN '
ADDRESS
544 reAy3MDRVA6A
-' ••
OWNER 7 `
CONTRACTOR / DESIGNER / EN INEER
NOKE CROW fG
L I31"J rN C+ ,* XWMR.M101T CO.
LA QU "I"A. CA 9225.1
;ifEAMa-C)A1'r C.A. 92223
USE OF PERMIT
465'.l?ADDITION "biPNY73di1)OW CH M-102 OUT IN,MISTIN00 11AVEJA. NO,
:I'kd�.t;'j' i;fsJ��.�tiJ�:"J`JQN 46a.gif AAs'
MATED COSIr OF CORTMUMOK
25;;9.
CONSTRUCTION FER 101 -000-418-000
PLA14 t: i'#.WK :rE)v !.W -WO -439-318 O -x$39-318 $209.32
MW . ANXIAL FEE 101-WO.421.>.WO $49.50
rNAL CT -K ICAI, FFE 101-000-420-000 $31123
P.LAiiJJI1M 0 FFX 101 -0130-419,-000 S48,R,1
STRONG MOTION
bbd,'. N 40 .FEE 1 L1-00t)-42MOO Y�6,fs9
MB=,t°Oa'AL CONST .U'C1 IOR AR'yD ,1i•'t..AN CSCK
$589.32
SEP 0 5 2001
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE " BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
,/
(O —8 —0 C
Exhaust Fans
O.K. to Wrap iofs
l0%q =0( 9 Z
F.A.U.
Framing
e
Compressor
Insulation
(p— 2-d S,T
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
la —l(
Final
Final �� 9� o L /�
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
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)
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)
COMMENTS:
Bill
w C►tyof La Quin to-,. .
°Building a Safety Divsion .
'Permit # _ P.O. Box 1504, 78-495 C0107ampico.
La Quinta, CA 92253 - (760) 777-7012
0108= -77 'Bq ding Permit Application and Tracking Sheet
A. P. Number: Address: 5L 05✓ Ul �[
Legal Description:17s - 2
V' V I City. ST. Zip: Urn /T 7 a
e j7 f: Tele hone: `
cjY1 C -0P g s d - a6 $
' Address:. 1: h Ave cProjeetDescript oon:• = - W I 7lli�1
City. ST, Zip: u 3
_ t
Telephone:
P
hon
e.
'e
5 K
l �Sf"ate Lt # , %R $ City Ltc. #: D✓)
Construction Type: It
Occupancy:
State Lic. #:
Project ct type (circle one):
1\e�� Add'n Alter Repair Demo
Name'of Contact P ona::� �" aaA�
. ,,.� -Q/�OS 1V� r%d eZ (•
•
'—r--- 1
Sq Ft.; s #Stories: # u1nits:
nits:`
'
Telephone # of Contact Person:x 0� _ �j —4�p�
Estimated Value of Praijeci:
- APPLICANT: DO NOT,WRITE BELOW THIS LINE
s
# -
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES a
Plan Sets
Plan Check submitted
Q
o
Item
Amount
F;
Z
Structural Calcs.
�. -
-
Reviewed, ready for corrections
Plan Check Deposit
Truss Calci.
Called Contact Person
Plan Check Bal ancc
i
Construction
Z
Title 24 Calcs.
Plans picked up
'
Flood plain plan
Pla�srcubsr
Mechanical
Grading plan
r ew•read�forcor ' ons/issue S
Electrical
Subcontactor List,
..
Called Contact Person - 61i:5_
Plumbing •
Grant Deed
Plans picked up O /
S.h1.L
H.O.A. Approval
l
Plans resubmitted
Grading
IN HOUSE:-.'
'"' Review; ready for correc ?Ons/issue 9!/
Developer Impact Fee
Planning Approval -
Called Contact Person /
9 /
A.I.P.P. , • .
Pub. Wks. Appr
Date of permit issue
School Fees7
-
9
AMA
Total Permit Fees'
','Desert Sands Unified School District
47-950 Dune Palms Road 4
Notice:. La Quints, CA 92253
-Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE -
Date 8/.20/1 µ; APN# 774 -223 -019 -
No. 22396 -' JurisdictionLa Qunta
owner NameNlike Cross Permit #
- No..54-175 Street Avenida Villa " '` Log #
City La°Quinta Zip. 92253 Study Area
Tract # _ Lot # Square Footage ' 465.
Type of Development Residential Addition No: of Units' 1
At the present , time, the Desert Sands Unified. School+ District does not collect fees ongarages/carports,. covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or r:placement mobilehomes: It
has been determined the above-named owner is exempt from paying school fees at this time due b the following reason.
ResidentialAddition 500 Sq Feet or Less
- EXEMPT .
This certifies that school facility'fees'imposed pursuant to Government Code 53080 in the amount of
0.00 X 965 r .- or $ 0:001 ° . , the property listed above and that building '
Permits and/or Certificates of Occupancy for this square foota in this proposed project may now be
r,
Fees Paid By EXEMPT ; Carlos'Lopez ' Telephone '909-845-9303'
Name on the check r '�,'
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow, Exempt $0.00'
.Check No. L...
Signature k
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you mak, protest the fees or other payment identified
Dove will begin to Fun from the date on which the building or installation permit for this project is sssued or on which they are paid to the Districts) or to another public entity authorized to
Alect 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 foe all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting ., '