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LICENSED CONTRACTOR DECLARATION
I hereby affirm 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. 4882.34 B i 2/30/97
License # Lic. Class Exp: D'at?,sa/
(Date SignatureofContractor
OWNER -BUILDER,'
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
r
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 ttie 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 Policy No.
(This sect�op n dirZ?t41b completed if the permit valuatioonjss:.1%$1100.00 or less).
() I certify tat 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 300 of the Labor
Code, I shall forthwith comply with those provision_se % d r
Date: Applicant
Warning: Failure to secure Workers' Compensatibn coverage is unl I and shall
subject an employer to crimin�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 results this.applicati.,o�� agrees to, & shall, indemnify
& hold harmless the City of Indian ulfefls'ts�officers, agents and employees.
2. Any permit issued as a result of is 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 in pection purpose
'Signature (Owner/Agent) Date
�fi3432"1321!
DATE
JOB SITE ADDRESS APN
44-1,130 CIRONTE RA ]DRI''VIE 1 604-272-003
OWNER CONTRACTOR
1,cjcrR SNEGLLFNBEROER. & ASSOC. .
ROGER SNE1,1.E€ei( ERGE,R &ASSOC 4186513OARIAVAlX #212 '
41855.80A DIWALK A -M PALIv! DES'ERI' CA 92211
PA1aM DESERT' ',.CA 92211 (15.19)777-7706 C8110 18511
(619)777-7766 DESIGNER/ENGINEER
CHARLES D.GAW AND
USE OF PERMISINGLE7 TAMIL it DWELLING 3-1-1.63 CATHEIDItAL CAWO�T DR.
QUYNT MICA
PL/iIJ i
.11
'! RAC I! CON_S,'1RUCf'1C)N 24015.00 SFE
GARiViEICARPORT 626100 V
ESTIMATED COST OF CONSTRUCTION,
3.21,684.:€0
PERMITFEE SUMMARY
,Pi;AAN c:`Ft1ECK RE
101-1100-439>3 41`09418
$597,06
CONS'MUCTIONA FLk,
101,000 -41S+ -M
$716.50
Tv1F,C"NJCt; L FF`C
IM -00-421-000
$53:36
.E, ECT121r.AL F1:E
101-000-420AM
$131.55
!'!.lijvl}3i?�If;l
N.(lS-INIII-4.,19-0f.)4' .
$15$,174)
ST0v,G'rv10'F10WF s`, -.W SI[:1
101-000-241-000
ORADING V ::
101-000-423-000
Sr!q.UO
-l`NF tA.`3': RV' FU,RR Mi
225-000443-342
$2,737.99
Awr 'N NE, ret C °10;1•-000-245-000
$51.21.
FEB o 6 1996
By
RECEIPT IDATE
AND PLAN CHECK
LESS PRE -PAID FEES
PERMff FEESDUE NOW,
FINALED (INSPECTOR
$4,476.
$0.00
$4,476.313
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
1711
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
01.
Exterior Lath
Drywall - Int. Lath
Final
Final v
BLOCKWAL PPR &ALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
i
O.K. for Finish Plaster
Sewer LateralPool
Cover
Sewer Connection
ffZ 76)eEncapsulation
Gas Piping
Gas Test
Appliances
Final
n
Final
Utility Notice (Gas) ?/
ELECTRICA APP OVALS
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 17
Utility Notice (Perm) EEE] -1 t / / -
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 2/2/96
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-272-003
No. 14097 Jurisdiction La Quinta
Owner Name Roger Snellenberger & Associates
No. 44830 Street Fronterra Dr.
City La Quinta
Tract # 23912
Lot # 103
Permit #
Log #
Zip 92253 Study Area 233
Square Footage 2015
Type of Development Single Family Residence No. of Units 1
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 2,015 or $ 3,465.80
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.
}� 4
Fees Paid By Roger Snellenberger & Associates _ Telehhoni"
Name on the check
By Dolores A. Ballesteros
Superintendent `
Fee collected /exempted by Pauline Pearson Payment Received $3,465.80
Check No. 11027
Signature 2t�,, �X,vtiJ P4 ,C1,V(.e1A�_
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
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