0210-256 (SFD)MIS
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
•$S�CJI 21 kt �'•.a fj 4w�� �•�" t�9%�i1JZt
��� P
;fD� '� �`j� 4 Signature of Contractor 4, '�" a
.. -
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. forkhis reason
r _? ";/—
Date/ It
rx_• 1 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 S,,r iTty gj1gD Policy No. MOWN
(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 thakif I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions..:
bate: f :. , Applicant'":'st=°.�
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 1P0 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.
f Signatufe,(Owner/Agent),"`rDated
BUILDING PERMIT PERMIT# _
VALUATION , �y 4p� yy� LOT 02 0'L'� TRACT
DATE ///
t
2- 1
JOB SITE
APN
ADDRESS_M L S in ,r E� �. ..:�A,
X774— —MM
OWNER
CONTRACTOR / DESIGNER / EN (NEER
DC1:i1 MV. CORP,y1�iTci
3 )� VA��I 4? ��°Y: CORP
PO BX 2982
?8-921 R,(aTKXAYA?-AY
PALM 1 1711kt .r CA 92261
BI.Iv(U!JA D't.)NES CA 92261
USE OF PERMIT '
1.1-33 SQ,t�"I. UVIN0, 44a SQ:VI'. aw`mV. PERMIT &es nrA
inclode bbdr in -6, fern -60, pool and bPa< .& �a)Dt�t fibu tj+3Fdl3r1
is ze.elwirat1 for -the rltivr w y aSm=6 fri;w the Pu4+li.t: Work-,
TRACT CONSTRUCTION 3,m.09 OF
,
POIZCi~t1P.,` TIO 241AW :T'
GARA /0'AIt.KORT 440,001LIT
MMIKATIU) COST 01? CX)MMUC170N
92,185.10
��yNy�,�jjq(!ps�y����+'/�l�E�:���
1.. 010SA'i�Ji• 0110J' FEE
PLAN CI ECR I'M $.5091M
BLEC TRIC AL ME,, 101-000-420-000 $1.10M
PI..'tfPvl}31NO F'EE 101-000-419-000 i$121.50
3TRe))4-0 MOTION FEE - REBID 101-000-7,41-000 *M
C.1Fd.WIN0 FEE 101-000-423-000 $15, 01`4
I r-orEWPER.IMPACT TF&F $2,465.30
- PRWIISEPLAN lQ}�_Urs��1dI�3�$ti �iOtS.lffJ
V
MS PREPATD, 017M0
.4250.00
DEC 18 1001 TAL FM'Vk' 1JITME0 DUN .TNOW
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY 1
DAT INAL D
INSPECT_
0-9
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
R
Ducts
Slab Grade
t (
Retum Air
Steel
Combustion Air
Roof Deck
— 01
Exhaust Fans
O.K. to Wrap
Framing
_ G
F.A.U.
Compressor
Insulation
(� 3 �_
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 ��_O_3 .�l/_(
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment- Location
Underground •Electric
Underground PI . .•Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
�- �3_ Q� ,��
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
O`
Appliances
Final
Final __ _
Utility Notice (Gas) S
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 G=�/
Final
Utility Notice (Perm)✓` �O
COMMENTS:
Date
12/18/02
No.
23968
Owner
DGH Dev. Corp
Address
P.O. Box 2982
City
Palm Desert Zip 92261
Tract #
Type
Single Family Residence
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
(760) 771-8515
APN #
Jurisdiction
Permit #
Study Area
No. of Units
O�J��PIF.DSc�o
Q BERMUDA DUNES r
rn RANCHO MIRAGE
J INDIAN WELLS
Vi PALM DESERT .y
LA QUINTA
tf3�INDIO `^
O YJ
774-080-004
La Quinta
i
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 53080 Eisenhower Drive 1533 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,533 S.F. or $3,280.62 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 CC/PDNB - Art Lamrose Check No. 085442
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Monica Guillen $3,280.62 $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
Certificate of Occupancy
City of La Quinta
Building. and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
53-080 EISENHOWER DRIVE
Use Classification:
SINGLE FAMILLY DWELLING
-Bldg. Permit No.:
0210-256
Occupancy Group:
R-3 Type of Construction:
VN Land Use Zone:
RC
Owner of Building: DGH DEVELOPMENT
Building Official
Address:
P.O. BOX 2982
City:
PALM DESERT, CA 92261
By:
KIRK KIRKLAND
Date:
MAY 16, 2003
POST IN A CONSPICUOUS PLACE