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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 # Lic. Class Exp. Date
9 B, 1 f2
t. t
o % X ✓ f�
Datee n! 1 y�/ J'� Signature of Contractor, :'f s• �" i F
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
I
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 j 1. l,fJ`t,D Policy No. 9.515265-02
(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 f A 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 . pe. rmit 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, 88 shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi I
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellati
I certify that I have read this application and state that the above informatio
correct. I agree to comply with all City, and State laws relating to the, build ng
construction, and hereby authorize representatives of this City to enter u on
the above-mentioned property for inspection purposes.
r J c J
Signature '(Owner/Agent).i`//`.
%�' L Date- /�*/
BUILDING- PERMIT PERMIT#
DATE j / y VALUATION LOT• ' ' r'�a-i'i TRACT
$28,714.70 1511 1ILK VI! U-2
/0
.(-, f ! ?
JOB SITE
ADDRESS !A--44qpNijNIDARERM.- v
APN
774-M-4 28
OWNER
CONTRACTOR / DESIGNER / EN (NEER
JACOB `'°CSrRM; _
h 0. °ANMES CC?Y? UPTIC'4 i0l
AVE52 - - .
8Vi,11?�00 l�e�1EMU 52, 030
y81.900
AND110 c, . 92201
qny
INDI •• 4«A�i x'1.2^1J1
"'i ii�'1? •,2$�,R CSIJ. 14,11
USE OF PERMIT
339 S.R ArjL-'1bT10K 0; 11705,K Lfkf']liLy (Ettl Ff?,PfiATTEf,,) GN.
V61iL1, ,JV-0AX, C: R MVF''W-AY'' JUpE`TRt%i9CH
COST OF CON91RUC71TON
ai�s„#��ii.,:�•-,�•.
1.''i'.k?°AM T) TM 91WAWY
CcaNMVCTI): F22, 10z-000.41S� <Xv'o $3XV)
P114.N ("H Ck;. ME 9 01-000-4'10 341, 8
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HLY,C'PIR%e:,X*L ". l x -}i c; :�An�pit a
f�,�-4c e:>s.
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1.
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JINN 16 2�D3
C6T` 1.M4
RECEIPT sem' 1 i 1,
DATE' 7,
BY_,t'' �� : -
DATEFINALED '
INSPECTO
011
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Bond Beam
Forms 8 Footings
Slab Grade
Steel
Roof Deck
Final
OX to Wrap
PLUMBING APPROVALS
Framing
/,Z • 0 3 5W7
Insulation
U-02
Fireplace P.L.
Plumbing Top Out
Fireplace T.O.
Shower Pans
Party Wall Insulation
Sewer Lateral
Party Wali Firewall
Exterior Lath
1,57
Drywall - Int. Lath
12- t/•
Final
OPERATION DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
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
-
Final
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Low Voltage Wirii
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
Temp. Use of Pa
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'din # zG
Nw Perot, -t -;F City of La Quints
0,jp4Q - U7;, Building 8L Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: 1� �rlL
wner's Name: �—
A. P. Number: '1 _ �,
fAddress:
Legal Description:
Contractor:
t%. ST. Zip:
FTelephone:
Address:
Project Description:
Cin•. ST. Zip:
fir Z n
'telephone:
�S p / (,iiwe.1 -4 2p .}t��•
State Lic. # : Cit-,• Lic.
Arch.. Engr.. Designer:
4 /-0,r �t
&2/Z - 620
Address:
Cin'. ST. Zip:
Telephone:
State Lic. #:
Construction Type: Occupanc%:
Project type (circle one): New Add'n Altcr Repair Demo
Name of Contact Person:
q. Ft.:
#Stories:
#Units:
Telephone # of Contact Person: �
PstimatedValue of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
Req'd
Recd
TRUCKING PERMIT FEES
ffbmittal
an Setsi1
Plan Check submitted ��
I Item
Amount
ructural Calcs.
Reviewed. ready for corrections
eck Deposit
Trus 5 Calcs.
Called Contact Person
n Check Balance
Energy Calcs.
Plans picked up
onstruction
Flood plain plan
Plans resubmitted
lechanical
Grading; plan
2nd Review. ready for correctio /issue
lectrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
INNHOUSE:-
'^' Review. ready for correctio /issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
6
I o3
School Fees
2 f' Z.6�4/
sr
Total Permit Fees
11
y33��
� �3
CERTIFICATE OF COMPLIANCE "�1FIEDsc
Desert Sands Unified School District �
Date 5/27/03 La Quina BERMUDA O
47950 Dune Palms Road
CA 92253 rn RANCHO MIRAGE d
7 INDIAN WELLSLM DESERT
'ter
No. 24467 (760) 771-8515 PALA QUINTA :V
�INDIO Y�
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Owner
Jacob Torres
APN # 774251028
Address
54-444 Avenida Herrera
Jurisdiction La Quinta
City
La Quinta Zip 92253
Permit #
Tract #
Study Area
Type
Single Family Residence
No. of Units 1
Lot # No. Street S.F.
Lot # No. Street S.F.
Unit 1
54444 Avenida Herrera 529
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
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 (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
in the amount of $2.14 X 529 S.F. or $1,132.06 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 Cash/Alex Torres Check No.
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Patricia B buzza $1,132.06 $0.00
Payment Recd Over/Under
Signature
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
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