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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 {{# {{��s� iLiiqc.. qClass Exp. D'aateyr�9 t
lir 447AD B HVIC 1 A.✓.7 R /2(
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Pate ljF-,O-g�L 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 , 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.
(q) 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 g�•�+p.I Policy No
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) J certify that in the performance of the wor 4or 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: J Applicant l ;� + -
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 Cit , and State laws relating to the building
construction, and hereby authorize eprerntatives of this City to enter upon
the above-mentioned property for V speclion purposes.
b'S'ignature (Owner/Agent)..- ✓/rj�' �_ Datey tit
°BUILDING PERMIT PERMIT#
DATE /VALUATION LOT 051111- TRACT
ID
1.2 28611
JOB SITEy y APN
ADDRESS CON'))96X,
OWNER CONTRACTOR/DESIGNER/EN (NEER
C(:lMMPINI:3IA rGIV. ILC '!,0.T -1U- D80M CON.TAOICrnO.INI
92211
(160)345-5154 CE1111'r $285
USE OF PERMIT
31402..1;. FAMUff T)V-M -►..WG
SPO/WITH lsTTACHM) OUROST HOU5,F -. I.. )T 12. ISFRMIT DOES'NCYT
INCLUDE ?OT..Lt;"1.a"-�''./�LL%FOOL, S..R&ORDRIVEWAY A"PRO.A64 if
PC+)E1CHIPATTO 521),00 Sf
0A At3'Et'CAIII30R:1" 97409 Mf
�.�'-m-M.& ED +C:Orr39.' OF CON -6- mg)'ano.k'i!
hh�hyyI��yyt"gqII�//►3�,+;.y�y��5''��
1rE�%17d�RUCTI01B d'!�'�.E
y �y + 6, �[� p�
101^'{11.)�2'�r,,(8'CI00
v"('72,00 �+/i l ,,++�1
�t.= f�.H�
PLAN CH.VC1: F'E2
101-000-439-316
$1,7f3.+9I
FEE Iil:f'C3 YF
101>,000-439.318
-S!,I►t4om
A'1T.C'MANICAL PEE
101.000-421-000
$ 83.00
ZLECTRICAL Pr:IZ?
101.0.00.420-t00
S2601 20
PLIUMBI1 aFROK
101-10-0041.1*9-000
$749,60
IMONO M(YTlON M,,- RUMID
101.000-241.000
$39,49
CPI",$ VI'N 3 Fall
$15.00
Dr!,LrOVRI2IMPACT FEE
1192440104
.l RX TO I7,.1MSIE
2?0-0005-0W
1437.21
SEC 19 2002
I,..Tv e7F LA e�tJ11dT
RECEIPT I DATE
FrRLTC.`i'�C7k�3 AND PlP2;-dA I c"TT�'R"°.K
BY
.Plu"11YIEIs, 1A Now
$6,6195.:311
&51186-11
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_ O
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck — -U
Exhaust Fans
O.K. to Wrap
'—
F.A.U.
Framing_
U
Compressor
Insulation
Q 3 _
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
I I
Gas Piping
PLUMBING APPROVALS
r
Waste Lines �/ �_
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Q.K. for Finish Plaster
Sewer Lateral
Sewer Connection
03 _
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
.7 23
Final
Final
Utility Notice (Gas)
ELECTRICALAPPROVALS
Temp. Power Pole - p /,
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power - Q
Final
Utility Notice (Perm) /�
COMMENTS:
n1 -Q {wr lo L iA-t os {� /�
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/OA-Tt U i! — 3 -6- 03 Ate---
teiELECTRICAL
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Comments Overpayent of $47.43 will be refunded. CC#305361 (La Jolla Bank) was for the amount of $10,197.45.
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 (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 4,743 S.F. or $10,150.02 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/ La Jolla Bank - Mark Bradshaw Check No. 305361
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Monica Guillen $10,197.45 $47-43
Payment Recd Over/Under
Signature d
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, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
CITY OF LA QUINTA SUB -CONTRACTOR LIST Wll,,690rl
JOB ADDRESS %x-35 I �ACarj-be GJn-� PERMIT NUMBER OZI x-1307 _OWNER �C�MA^J&4�✓ LLe- BUILDER '�S
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade / Classification
Contractor
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
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111 �Go
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POOL (C-53)
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REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211 .
Office (760) 772-7192
Fax (760) 772-7193
Paget (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE RUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ S�}o
Cl OTHER
JOB LOCATION 7(yam �A cotl 0 A L A y U `w�
1�
REPORT SEQUENCE N0.
TYPE OF STRUCTURE
PERMIT NO.
DA O
DAY OF WEEK
MATERIAL DESCRIPTIONARCHITE
3
T
40's N
INSPE T R
T
HRS. CHARGED
ENGINEERq _ Ar `
1F !Rl nSUGB`
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL
DATE CONTRACTOR k.(,4 CONTRACTOR C1 } lam\
D�
,(o k
,S (,WQ.Q z Itt�
o 0 7,
TK -S V S14YKS
� 0
COPY SENT TO CLIENT O
CONTINUED ON T PAGE Cl
PAGE
OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
KNOWLEDGE ALL'OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS, SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
fl T RE OF R GISTERED I SSPEECCTORO
/Z
ATE 0 REPORT REGISTER
RNNUMBER
Certificate of Occupancy
U
ar�,
`,� Ioaronhn�
roar
OF Building & Safety Department
ti
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 78-351 DEACON DRIVE WEST
f
Use classification: SFD Building Permit No.: 0210-130
Occupancy Group: R-3 U-1 Type of Construction: V -N Land Use Zone: RL
Owner of Building: CONMANDIA DEV. LLC Address: 44-850 LAS PALMAS AVE #E -
¢
City, ST, ZIP: PALM DESERT CA 92260
By: KIRK KIRKLAND
Date: 11-12-2003
Building Official
3
POST IN A CONSPICUOUS PLACE
a� `L•c
�-- ,- Certificate of Occupancy
._"
IN RATED
OF'IZ Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
i
construction and/or use.
BUILDING ADDRESS: 78-351 DEACON DRIVE WEST
I
I
i
Use classification: SFD' Building Permit No.: 0210-130
Occupancy Group: R-3 U-1 Type of Construction: V -N Land Use Zone: RL
Owner of Building: CONMANDIA DEV. LLC Address: 44-850 LAS PALMAS AVE #E
City, ST, ZIP: PALM DESERT CA 92260'
By: KIRK KIRKLAND
'
R
Date: 11-12-2003
Building Official
POST IN A CONSPICUOUS PLACE
; , i
M
Certificate of Occupancy
4
`yG IncasonnTm�
OFT9� Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 78-351 DEACON DRIVE WEST
Use classification: SFD Building Permit No.: 0210-130
Occupancy Group: R-3 U-1 Type of Construction: V -NE Land Use Zone: RL
Owner of Building: CONMANDIA DEV. LLC Address: 44-850 LAS PALMAS AVE #E
City, ST, ZIP: PALM DESERT CA 92260
By: KIRK KIRKLAND
d'1i'l Date: ' 11-12-2003
Building Official
POST IN A CONSPICUOUS PLACE