0101-328 (AR)N
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LICENSED CONTRACTOR DECLARATION
`;f 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
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 theJollowing 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).
(r) I am exempt under Section B&A' . or this reason.
Date-,. �. ti i, Signature of Owner
` .�, ,
WORKER'S COMPENSATION DECLAFIATION
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 permitis issued.
O I have and will maintain workers' compensation insurance, as required by
Section 3700 ofAhe 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 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 permitis issued,
I stall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califo nia, and agree that if I should become
subject to the workers' compensation ovisions of Section 3700 of'the Labor
Code,, I shall forthwith comply with thosei ovisions.
Date:. Applicant
J �
Warning: Failure to secure Workers' Compensation co4age is unlawful and
shall subjectan 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*
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 propeity for inspection' purposes.
"Signature (Owner/Agent) �` �L Date
1�
BUILDING PERMIT. PERMIT#
DATE VALUATION• LOT �,�E-, TRACT
7 18 70M
JOB SITE
APN
ADDRESS
70-•82D WFS 11AW.AM)
604-231--r"
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1v►.►UM :PN;XE.:I 41
O'UifllwlL4�lI+r1111.L7k f�.
78-820 WN"31r:t AWdAND
-i:,.A Q(:i<,fNTA CA. 92253
() t:'F? 4
USE OF PERMIT
!',EMDEN"f1:AL: A-1JDW1014
Alt- :3..'t'. 'k00M .A.VDI'Piti'N AN PER APPROVED IRS CML`r*.
ADD.1:VON M,00 Zip
ENU WATED C'.O %TOF +w'ti?T9M2-ElMON•
481811M)
PERM11TE SUMMARY
PLAN CHTFVX .RM 101-000.4 39.318 U0129
CC NISTIZUC"I'I N FKE 101-000-418-000 $408.00
MVk.".1�,1VILALk+ET lfll> >4:21•000 845,00
IQEXTR1C.A L IFFS, 101-000-•A; 0-000 $4.5.00
IAF.,<r„Iii ISk"ta141 I�':1+; 1') I t7i1✓:1.4 i `.�wC►C1D $�;$, QQ
57R.CiNCI HOTION t*ZO - R.&SID. 141-000-241-000
C4196,11(-11014 ANI) K.AAN CHEM
03AL
1XV9 PRE-PAU)PUB
$0.00
r
FEB 21 2001
3A ' �t.[�..�'.[rX,09�)U NOW
�:113t6.09
ao8 A 9 V v L uUV
RECEIPT
DATE BY
D T INALED
INSP T
1.1 . 1, V
NSPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
S
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap �L//�l gpar
Framing ���p^�/
rf
F.A-U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
;, 411
Drywall - Int. Lath
c9'
Final
Final
HLOCKWALL APPROVALS
Steel
(POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond. Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
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
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)
COMMENTS:
'
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.Bin
City
of La Quints
Building,
at Saf0ty Division
P.O. Box I SO4
penwe.#
78-495 Calle Tampico
Building Permit
La Quinta, CA 922-53.
Application Tracking Sheet
and
Project Address -1 b-fto W. 4WAND
Owner's Name: 0 We T i'LCAH PSI U 1 P5
A. P. Numb.er, 001 2.31 00
Address:38 -6,o 0 . 9MUMJ3
Legal Description:
Zip: sk qLA I te,
City'ST 9zz 53
Contractor: 6W+,Li1/' z A
Telephones -
Address:
Project Description:
City.ST. Zip:
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Telephone:
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State Lic. #tr
City Lic.
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Arch.. Engr—Desiper: MrHfj, ftr
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Address: $2, 1
City. ST. hG 922,E
Telephone:
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Cons trUCU on Type: Occupancy:
State Lic.
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ect circlemne): New Add'n Alter Repair Demo/
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Nanwof Coritact Pe�on: ter. .
S # Stories:.
# Units:
Telephone 0i of.QontW Person:,
Es;o;�ted Value of Proj
#
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Desert Sands Unified School. District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253 .
Document Cannot Be Duplicated 760-771-8515
Date 2/21/01
No. 21683
Owner.NameWM Phillips
No: 78-820
City La Quinta.
CERTIFICATE OF COMPLIANCE
street West Harland. Drive
APN # 604-231-009
Jurisdiction La Quinta
Permit # 010.1-328
Log'#
zip 92253 Study Area
Tract # Lot # Square Footage 900
Type of Development Residential Addition No -of Units 1
Comments
is a bedroom/livingroom/bathroom.
At the present, time, the Desert Sands Unified School District does not collect fees on, garages/carports, covered
patios/walkways, residential. additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying: school fees at this time,due to the following reason,
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.05 X 900 or .$ 1,845.00, the propertylisted above and that'building .
permits and/or Certificates'of Occupancy for this square footage in this proposed projectmay now bd issued
Fees Paid By CC/Bank. of America - Brent. Phillips Tetephone
Name on the check.
By Dr. Doris Wilson
Superintendent
Fee collected /exem ed'by Annette Barlow
Signature
Payment Received $1,845.00
Check No. 40250.4087
NCIMCE Pursuant at Assembly Bill 3081 (CHAP 50, STATS. 199 n this will serve to notify you that the g0•dey approval period'in which;you may protest the fees or other payment Identified
above will begin m run from the date on which the building or installation permltfor thls project is ensued of on which they are paid to to Districts) or -to another public entity authorized to
collect them on the DisblctCs)(e) behaH,.whichaver is earlier.
Collector: Attach a, copy of county or city plan check application form to district copy for all waivers.
l;cinbossecl:Original-Building Dept:/Applicant Copy - Applicant/Receipt Copy - Accounting