9810-050 (SFD)C%4
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LICENSED CONTRACTOR DECLARATION
$1i;1
I herebyaffirm 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
291721; 13 $/00
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 937.7!Policy No.
yU�� :s U$lT 0(014V
(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 inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMITS
X0'0511
DATE VALUATION �Sn ,,6", . i1JA LOT 22 TRACT DC
JOB SITE -41-300 CALLF, (�UAT E'1% Lei
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'51'Ai;T,1GN Attl.'9.A IEN11'1 N17
Vti.'IWAA4 RUSSELL ROOERS
PO BOX 35718 �
5ze-900 JACKSON
PALM DESERT CA. 9.1261
T1TL4L1l4AL 'CA 92274
(760)399-1200 is 31. ` 5"9
USE OF PERMIT
�iN�►1,:I.�,AiVit�,�'.iaw�:Lii�
.
�
SFD -11 T DOES NO x .iNCLIUDE BLOCK WALL OR POOL
TRACT NtlitiiS`1"sitii iDid 1.2(9,".40 a.F
Po tCiiFf7 1,10 11<4.4iCt S?r
iYA3.tAiltriCliRt?+;i�'l" ylo.tf4.1 tit'
ti F'r. Wool) "NCF .22.0) LF
ESTIMATED COST O.l i��fJ.NST1?�.r�.".TIGN
� �,g�g�p,{
g^y9 �g y- FEE
i-41
CON.';>`ritVU tUl+f FU.1 101-(►U4)4lfS 00 $557.50
'P1-A'N ('.FWfK FFf; 101 -(X10 -419-31K 'U81 AA
13 tyf.°l fOCA11 ElE1 101 -WO -420-000 $125. Ri
PLON3.i31aNO, FEE 1()1-tiO4.419-000 S133.5N
A'I'(tr)N(Y 4df�"►q'if1Ab (rFt�; _'a?'P�3t3 ii1-fl{i!?�?�4i,.('!{}(! �R.ai
ORnf.7TNG FEW 101-000.421000 Sy(t.Ot)
lNFRAti'.MUCTi3i2 , FIX, 225-000-443-342 S ts3lkl.Sti
HtV- C ISE PL AN 10.1-000-441.345 535,00
r,t_l! OrIPC3SIT 101 ^ 0A_1"t9_3i9 _S250 (IA
5014- fM'AL. COMM T'RUCTON .ANE) PI,NN t'.1.-{1ECIK:
$3,2273-1
p �+y
CO AI, P3+i1MT WES DUE; lel' W
S2,977.33
RECEIPT
DATE
BY
DATE 0NALED
INSPECTOR
INSPECTION RECORD
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
O.K to Wrap
F.A.U.
Framing
EjaVents
Compressor
Insulation
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 P OVALS
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
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
IMr Connection G -7-4D-ff,Encapsulation
Gas Piping
Gas Test 4-(S
Appliances
Final
COMMENTS:
Final 4 3W
Utility Notice (Gas) I ti IWI "Ir
ELECTRICAL APPROV
Temp. Power Pole / Q
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)
' � . •�"�'��'�"�!'�' `r },;• • �i SMF '. ',•
scop �
• • • , , � � � j �^ ,. �'r� ,dip � - • . - f;
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r� ' 'J . �I 'i �I' � ',;,'...y.• •.i' ,,. i f , ��• • 45 � s"{:': :y' r•f.F' .� �J' ,. . � ... •• � .
R�
�• ' . � •. :i ',� . �, ��, •, ill" i. f'
- -' LICENSED CONTRACTOR DECLARATION
"'" a I•hereby affirm under penalty of perjury that I am licensed under provisions of
to
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
w;•_cam W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
o 2917215 �3 , �r W31/00
ft tZ' �Ri/! 4
o Z to ���Signature of Contractor, 0. 4r
J U OWNER -BUILDER DECLARATION r
HLU r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
C) cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H p () 1 have and will maintain a certificate of consent to self -insure for workers'
X w LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q pe,rt pm ince of the work for which this permit is issued.
m Q U 4. (x) I have and will maintain workers' compensation insurance, as required by
O LOQ Section 3700 of the Labor Code, for the performance of the work for which this
Il 0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carrier Policy No.
oo =) S � A E rung 2 4^n-rrt;. IIN r 0004443
�a
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
aC de, I shall fo hw�iith comply with those•p�ovisions
te: ¢ Applicant'"_'` ���r
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 riinspection-��i4purposes.
Ll
Signature (Owner/Agent) _ t' Date %
BUILDING PERMIT PERMIT slo-o50
DATE VALUATION Wfigl(A) LOT 2-2 TRACT H5, EX,2
c
JOB SITE S 1_ 114) ���� !. �iZ1:� r�1sA
ADDRESS
APN 769-113'-0(
OWNER
CONTRACTOR / DESIGNER / ENGINEER
STARLItr if.r MANAGEMENT
W11.IIAN1 RUSSELL ROGE S
PO 'r30X '_4V8
56.900 3ACKSO;N
PALM DESl R1" CA 92261
T TMMAf., CA 92214
(7€0)309-1.200 CE11.0 5�9�19
USE OF PERMIT
WD - PERMIT DOES NOT ft,�CL'UME BLOCKWALL OR POOL
TRACT C014SVEITC7.MN 1.296.00 S"
PORc"M)At iO 114.0 W
QA1(AOEYCAAP0kf 515.01) S
6 ,%".c. WOOD f -T% SCF, 200.00 L
NTAT *4
PwRwT PcF' si1;ti m.m1V
C0..N!T,,f,RUC`.1'1(.)N FHE 101-000-41. 1-0410 SSft9.Si)
P11.N t <;911111 wr_F in,1-/?fh'1-439-��t5 fR3.telA
h1ECILNINICAL FEt, 101••00,0.421-000 $53.50
Ef.[x;"fRfCtkL "r'FE 301 -OW -120-0001 tIZ.16
P1.UMI31NO KEE 10.1-000-419-000 5133.50
STIRONGhCG-y, r1raN ITT, - IRr`' 0 101 -000 -24) -MI) $9.37
GRADil<O.M3 101-000-423-000 $20,00
1WFRM R1JCTUR FE6 �N5-•000-"1342 $1,810.50
RECPSE PLAN 101-4)W-441-345
«; FFT 1F-POS(T fil 0(X) -43A)-318 _$4wb.fJ(►
a
`tit -'rY -i:. C Mti?'tat.iCTION . ND I -AN MI CK
x KESS 101{:104",A1D FL
4250,N)
NOV 19 1998 TOTAT ftJRMIT PEEN DUE, NONV
$2,977.33
FICEIPTii�
DATE
-1
BY
DATE FINAL
INSPECTOR
/1'
It °
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
— - ST
F.A.U.
Framing
— _ s
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
y- ZL — 5;,7
Drywall - Int. Lath
--2 3 - %lt S
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
/Zl
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
—(f--t4 S
Appliances
fO?fc.
IT ;z4 -
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) C L
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 11/18/98
No. 18011
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameStarlight Management
No. 51-300 Street Calle Guatamale
City La Quinta
Tract # B5, DC2
Lot # 22
Type of Development Single Family Residence
Comments
APN # 769-113-003
Jurisdiction La Quinta
zip 92253
Square Footage
Permit #
Log #
Study Area
1,296
No. of Units 1
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
1.93 X 1,296 or $ 2,501.28 the property listed above and�that building
permits and/or Certificates of Occupancy for this square footage in this proposed project:riay row be issued
'A
Fees Paid By CCNalley Independent Bank/William Russell Telephone
Rogelb Name on the check .►
By Dr. Doris Wilson ° ' T . g L•
Superintendent
Fee collected /exempted by Juanita Green Payment Received $2,501.28
Check No. 177042
Signature
NOTICE: Pursuant of A mbly Bill 3081 (CHAP 549, STATS. 1996) 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 fr the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the Dislr ('s)(s') behalf, whichever is earlier.
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
Order -No.,
Escrow No.
Loan No.
WHEN RECORDED MAIL TO:
STARLIGHT MANAGEMENT
P.O. BOX 1356
BORREGO:!:SPRINGS _'CA' 92204
5/ - 3 00 CAca a d
NAIL TAX STATEMENTS TO: SPACE ABOVE Trus LINE FOR RECORDER's USE
DOCUMENTARY TRANSFER TAX $.39.= ............................
STARLIGHT MANAGEMENT ��"' pu�eNd aIn thegcponsideration or value of property conveyed; OR
P.O. BOX 1356 -�omOputesc%n tfie cloC^sidera�a^ or value less liens or
BORREGO SPRINGS, CA 92204 encumbrances remaining it time of sale
Signature of Deciarant or Agent determining tax -Finn Name
APN: 769-113-003
TRA:
GRANT DEED
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
JAMES H. DAUGHTRY DBA LA QUINT MORTGAGE
hereby GRANT(S) to STARLIGHT MANAGEMENT, -INC .
the real property in the City of LA QUINTA .
County of RIVERSIDE State of Califomia, described as
LOT 22 OF.TRACT DESERT CLUB TRACT UNIT'.: NO. 2, IN BLOCK 5, SHOWN BY MAP
ON FILE IN BOOK 20, PAGE:($)6,' IN THE OFFICE OF THE COUNTY RECORDER OF
RIVERSIDE COUNTY.
Dated
STATE OF CALIFORNIA
COUNTY OF (ZLrJF_¢S10� }
On i % 1P. before me,
personalty appeared r
personally known to me r '.Q< vPd to rnp nn the hams ZL.Sakswatery
owitlar�er( to be the person(s) whose name(lIGbrasubscribed to the within
instrument and acknowledged to me thaey executed the same in
(S5&uAheir authorized capacity(iee . and that b r( Y�tgnature4
on the Instrument the person(gor the entity upon behalf of which the person
acted, executed the instrument.
11043 414�
/MES* H. DAUGHTRY
DBA LA QUINTA MORTGAGE
Wtr% IPICsLE
Comffdulon It .1170818
Notary t'ublic - California
.Riverside County
My Cam. Fgies .Ian 24.2002
WITNESS my hand and a cla
Signatu (This area for official notarial seat)
LC44TAX STATEMENTS AS DIRECTED ABOVE 1002 (1/94)
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY 9o— //3 _ OO
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL .SYSTEM
APPLICANT. Submit this form with four copies of a SCALED plot plan (1-20 SCALE) drawn to County specifications as indicated on the attached check list.
A non-refundable filing fee is required when the application is submitted. Check must be made payable to the Coubfit-(O flhR�jsiQiR 70Ng35N this applid78 ,
tion shall remain valid for a period not to exceed one year from date of payment. 5135 $214.
WB -r" (- � %V Gar- 1A Q atI� S'! $ 214 — 0M
r,
Agent, Contractor, Contact Person JAddress City Stat , Zip Telephone -
S � 0 Fax ? S 78' J.2 I
Owner Address City State Zip Telephone
a iY1v �c�•y+�t
Z Job
ZZJob Proper Address City Zip
F-
5/- .S 00 CAC CE CVA I"A14U 1Q 0u,,;V7A
IU Lot Size ater Agen Use of Permit, P/P, SUP, PUP, etc. Legal Description
SO X IOC / 04 Cr�E CC i1AC t--yryuef"Nt c.�/q�7 C4/Wr LOT as Bcoc,� � Arfa% C( ka
4rr,4 167nr T� Dwellin .(/29b Cr ��4Cr �/✓/J' v�
Signature of Applicarlt Date
_T
"I CHECK BOX IF REQUIRED
1 If any box is checked, this application shall be considered rejected until ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
the information is provided and the fee paid. Resubmittals later than 90
Mdays after date noted below may require repayment of fees. ❑ Staff Specialist Lot Inspection Required '
m ❑ Holding Tank Agreements Completed Thomas Bros. Page Grid
Z ❑ Certification of Existing S.D. System Required
III 0 ❑ Date Lot Inspection Completed: Initials
U❑ WOCB Clearance Required
LU (Attach for DOH -SAN -007, Santa Ana Region Only) Remarks:
❑ Soils Percolation Report Required ❑ Maintenance Booklet Provided
❑ Special Feasibility Boring Report Required
❑ Final Inspection by Department of Environmental Health is required.
❑ Rereview Required Initials Date Please call 24 hours PRIOR to inspection.
,
j
I
C/42 / Soils Percolation Boring Report by (,/ Lic/Project # Date
Soils Map Page 1 Soil Type TT , G6 �1 Approved By Date
t
No of Systems Pp9 .System(s) No.Dwelling Units r (1) Septic Tank Soil Rate G se/Sand
ing Tank ❑ Replacement Bedrooms, Grtcp/Lint Trap,
❑ Addition 30,m -f �� ,4& N14jl/OQ'� Gal. d. '�ting Gal.
Sq. Ft. Total Linear Sidewall Allowance Lqach Bed sq. ft. of
` m Area Bo m Area
I ock/ sq. ft. running ft. Install ft. long ft. wide with
i Inlet Tested Depth ❑ NA min. inches r 81ow drainlines or
U Proposed Bottom Tested De
Z Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Other:
OTotal Depth Allowable
Applicable / Depth
N/A Overburden ctor TD~ �� 3 /
1 . u,..i Ann.nva,•Date: Well Drilling Permit #
Utn-ANIV•1ZZ ipso aloof uiauluuuVn. •�nnc�iuwv niv, �c�wr�—nNMn�,a�u, ruvn—ciuy. uoNt., uvcuci�nvc—rml m/nvcuiuv
i
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:
Plan Check On Approved: Date:
REMARKS:
NO 4a&"e_ ez- 1,2 -
This application isPPROV
FOR OFFICE USE ONLY
Wawe, regarding thIgn of a subsurface disposal system as indicated on the
aoompanied plot plan, using the requirements set forth in SECTION C above. A build-
�7
s/�J, /�� 3 p�
ing permit is necessary for the installation of the above-designed system. No con.
Revenue code 1 0 Fee $
stetctlon Is parmittad In the requlred reserved 110% expansion area.
Ca1cQ JN
Septic Tank must bes:Weminimum from any wells. �l r ^ ' "�' F'T b^^
❑ Check A►
THIEF /
(2) Leach lines must be 100' minimum from any including
Date �ary!� — 7 O Initial
wells, expansion area
/ lines must be 5(Y minimum from any wells.
Z3
iewer
r
4) Seepage pits must be 150' minimum from any wells, including expansion area.
r2EF1./ G1/ai Main
Signature of Health Official
Date
Utn-ANIV•1ZZ ipso aloof uiauluuuVn. •�nnc�iuwv niv, �c�wr�—nNMn�,a�u, ruvn—ciuy. uoNt., uvcuci�nvc—rml m/nvcuiuv
i
T, iht 4 4 Q. "
P.O. BOX 1504 APPLICATION ONLY
Building e� 78 105 CALLE
LA QUINTA, CALIFORNIA 9
2253Addre_/_72
Owner �'7 %
tv-4.Z
Mailing I
y- i F, , L `
Address
City Zip Tel.
_ G� , GlL26-�7e� 6 0-7 q -/5
Contractor
Address
ty lZip ITel.
State Lic. J City
& Classif.
Arch., Engr.,
Designer
Address Tel.
City Zip I
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm th I am licensed udder ❑rorislons of Clhapter 9 (commencing with Section
7fl0gj of Divlsl n 3 b t a Business and r6le ions Code, and my license is in full force and
effect. �)
SIGNATURE `� DAT E
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the fallowing
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which regEres a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that, he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500).
17 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I 1 I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
11 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
f7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner _
NOTICE TO APPLICANT: If, after making this Certificate or Exempficn you should become
subject to the Workers' Compeitsa8on provisions of the Labor Coda, you must forthwith
comply with such provisions of fhi$ permif shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this appllcatlon and state that the above information is correct.
I agree to Comply with all city and county ordinances and state laws relating to building
consiruction, and hereby authorize representatives of this city to enter the above -
mentioned property for Inspection purposes -
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number t �' t Lzz -
Legal Description /m V c-,— ITfUR
Project Description
off 1 L..
Sq. Ft. ��- 4 _ No. No. Dw.
Size Stories f Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
Plan Chk. Dep,
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by,
Validation:
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DESERT SANDS UNIFIED SCHOOL DISTRICT
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated
(619) 347-861
Date 12/28/92 Type of Permit I La Quinta
No. 111918 Permit #
Owner Name Royer Snellenberaer Log
No. 51330 Street Calle Guatemala
City La Quinta Zip 92253 Study Area 112
APN # I Tract # Lot # 0 Square Footage 11218
Type of Development ISingle Family Residence No. of units L�
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 1.58 x 11,218 or $ 1,924.44 have been paid to D.S.U.S.D. 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 Roger Snellenberger & Associates Telephone 564-0793
Name on the check
BY James F, Lively
Assistant Superintendent, Business Services
Fee collected /exempted by Vickie J. Durrett
Signature ��C�Z�. .✓�c�I
Payment Received
Check No.001921
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
CALVIN C. KAMINSKAS
Assistant Commissloner
(714) 275-3000
OFFICE OF
AGRICULTURAL COMMISSIONER
JAMES O. WALLACE, Commissloner
83-612 Avenue 45 Suite 7
Indio, CA 92201
(619) 342-8291
DAN RILEY
Sealer, Weights & Measures
(714) 275-3030
DATE /gz�z CASE NO. �C�C �� `�.2
DEVELOPER'S NAME- WQ ,r S t P 'r e / e Y %P"
ADDRESS : --F,' D, V9 O x I a -
TELEPHONE: [ ) 0 -6775
Dear Developer: 8� `r I Lz\ (1 k,- ; G.
After reviewing your landscaping plans, all pla t material listed is not in
violation of quarantine laws governing the Coac ella Valley. If substitutions
do occur and they differ from plant material li ted, this office must be notified
immediately.
Thank you for protecting and preserving the Coachella Valley's pest -free environment.
Agricultural Conmis is Office
cc: Indio and Riverside
4080 LEMON STREET, ROOM 19, RIVERSIDE, CALIFORNIA 92501 — FAX (714) 275-3012
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