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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I arri 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 # Lia Class ' Exp Date
I1 1Y28V07
Date. 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 SiOnatura of nwnPr
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
heperformance 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:
Carter 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'mahner so as to,become subject to the
workers' compensation laws of California, and agre4 that if I N hould become
subject to the workers' compensation provis ons of Section 3700 of the Labor
Code„I-shall fo hw))th comply with\ hos s.Rcovisions.
Date:.” 4W 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, slid State,laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propedy•fo, or i�nspectiotlpurpose"s.
Signature (Owner/Agent) _` "--1-'� �'t �"�---- Date
PERMIT # CONTROL #
BUILDING PERMIT ►;��.► 9. 2 9 o r
DATE i.It VALUATION `$1,6&212- 403. LOT" 23 TRACT -W, -1i
j- INSPECTION RECORD
V -OPERATION
DATE
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
0 to Wrap F.A.U.
Framing Compressor
Insulation 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 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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) ;
i s
' fr
Notice:
Document Cannot Be Duplicated
Date 3/19/96
No. 14280
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 769-631-019
Jurisdiction La Quinta
Owner Name Fairways La Quinta Permit #
No. 50405 Street Grand Traverse Log #
City La Quinta Zip 92253 Study Area 125
Tract # 25389-1 Lot # 23 Square Footage 1
Type of Development Single Family Residence No. of Units 1
Comments
Grandfathered 201sq. ft.
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:
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Mitigation Agreement
in the amount of 628.00 X 1 or $ 628.00
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 La Quinta Fairways
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature P'(� I A I eAA .(JX A 4 _6,4—
Desert
6,4 -
♦ o
Telephone
Payment Received $628.00
Check No. 2472
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
CITY OF LA QUINTA
BUILDING & SAFETY DEPARTMENT
717-7012
INSPECTION REQUEST LINE
777-7153
ner FAIRWAYS LAUINTA
tractor AYRES CROUP '?". (� i:"
-
-rnit Number
POST ON JOB IN CONSPICUOUS PLACE
SPECTOR MUST SIGN ALL APPLICABLE SPACES
50-405 CRAND'I'RAVERSE AVE
IBADDRESS
ISFD L01'23 PLAN 3
TYPE OF INSPECTION .)A rE INSP.—
NDATION 8 SETBACK—
TING STEEL %,—_1/j:5pZ t _—
IN GROUNDS STEM
OUND PLUMBING — _ zi L� 7�• ��'�< (—'—
E-GUNITE i
NU i NVUH GVNGRETE UNTIL ALL ABOVE HAa BEEN_SIGNED
NCRETE SLAB TTS
STS 8 GIRDERS
CTRICAL GROUND WORK
NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
'JGH ELECTRIC
—r j
•"""--'—___..—i _ _—_
^U
UGH PLUMBING �
UGH GAS 8 GAS TEST
TING 8 VENT. A/C
OL PRE PLASTER
EPLACE
L FENCE 8 GATE
OF
L
—^ __
ND BEAM
_
h
TO WRAP
I
OUT C 4' O 8'
MING--
ULATION --
•'._ �1`?.c" � • lir' _
E -ROOF
NO WORK UNTIL ABOVE HAS BEEN SIGNED
YWALL INTERIOR
1COVER
tERIOR LATH
! (_— T C•�_�
OL PRE PLASTER
_�—_ rE
L FENCE 8 GATE
r
ER SEPTIC TANK
—^ __
FINALS
-CTRICAL --i A) G
MBING II _
AL GAS TEST —�—
TING • A/C__ --
USE NUMBERS
COMPLETED
MP POWER
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO -
TURN ON UTILITIES OR OCCUPY BUILDING