9709-075 (AR)F1
LICENSED CONTRACTOR DECLARATION
-I libreby 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,'ofContractor
ti
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 reasons
Date /1' ;A,.- Signature of Owner
f' 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 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 Policy No.
fir IIJ."1i %11 41;;1. 3,i1 iir'�j,
i'a ti ji ; i i�t.L4fit
(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 Q
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.
J a
Signature (Owner/Agent) `' . _�-''� Date /%i
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BUILDING PERMIT PERMIT�7i�F117� CONTROL#
5 914
DATE VALUATION S29.514,31) LOT TRACT
ADDRESS CJ •. f t;tS%.hZ1tCf�' :Zt i)k1t i�:
APN 77.t -1.3S-013
-OWNER CONTRACTOR / DESIGNER / ENGINEER
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USE OF PERMIT
t I)ON
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TV ryC1 OF LAi
�Yt .
;RECEIPTDATE
BY
DATE FINALED
INSPECTOR
2
1
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 Ty
Exhaust Fans
O.K. 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
BLOCKWALL ApPkOVALS
POOLS - SPAS
steer:,
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. 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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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
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Final
Utility Notice (Perm) VY
COMMENTS:
Bm #
City of La Quinta
Building K Safety Division
P.O. Box 1504
Permit #
78-495 Calle Tampico
La Quinta, CA 92253
Building Permit Application and Tracking Sheet
Project Address:.5/ — as ye
S D.-.
Owner's Name:
A. P. Number: 173 / 3;9 — 0/3 —zP
Address: CORONEL TION'
RO Box 389
Legal Description:
LI IP
Ciry,ST, Zip: La Quinta, CA 92253
�.
P. . x389
Telephone:
0Contractor:
Address: La Quinta, CA 92253
Project Description: o,J
City.ST. Zip:
Telephone: '.��o�" 14%0f
State Lic. Co3 It 5'el
City Lic.
Arch.. Ener.. Designer:
Address: OORONEL, CONSIR
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t
7 3 0 SR. Ll
Cite. ST. Zip: P.O. Box 389
8 $ e 3.3
Telephone:
'
53
Construction Type: • Occupancy:
State Lic. a:
:.«':::::::-`. ,:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephoned of Contact Person:
Estimated Value of Project:
-::APPLICANT',':.UO
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T9E4tertnlfYees
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA.92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 9/17/97
No. 16096
Owner Name Esequiel Coronel
No. 51540 Street Eisenhower Dr.
city La Quinta
Tract # Lot #
APN # 773-135-013
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Square Footage 473
Type of Development Residential Addition No. of Units 1
By
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 473 or $ 0.00 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 n/a Telephone
4
Dr. Doris Wilson
Superintendent
Fee collected /exempted by Pauline Pearson
Signature
Exempt a -$0.00. .'
Check No. n/a
40TICE: Pursuant of Assembly 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
rbove will begin to run from 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
:ollect them on the District('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
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