9609-025 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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
CIJ LU Professionals Code, and my License is in full force and effect.
O c•D License # Lic. GI ss Exp. Date .
ir� C) _LID 425,381 B I131/96...
UJ
ZO ate ignature of Contractor e. CIE,v�
U °) OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ aLicense 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):.
C0 () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
U Q 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
i A't'tj x: [ f t2 > i ?S4;t,•"Ay- trr
permit is'ssued. My workers' compensation insurance carrier,& pbllcy 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 permit is issued',
I shall not employ any perso, In any manner so as to become subject to the
Workers' compensation laws oftCalifornia, and .agree that if I should become
subject to the workers' compenslion provisions of Section 3700 of the Labor
Code, I shall forthwith comply with os pr visions.
Date: (- • L �t > Applicant t+
Warning: Failure to secure Workers' Co RRensation coverage is unlawful and
shall subject an employer to criminal penaltids 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. hull 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
co erect. 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 prope or inspection purposes.
t� U j
Signature (Owner/Agent) �L k �\ Date i
PERMIT # CONTROL #
BUILDING PERMIT. gat►-+>zg 411
DATE VALUATION #'6.� ?,01) LOT TRACT '
JOB SITE D-`J.1�.�S.i':t�11'11�., ii%I'
APN
.ADDRESS
O IVER
CONTRACTOR DESIGNER ENGINEER
PAC iC rYE,
PACIFIC 111.1k,E)S
P.O. BOX 722
P.O. BOA /22
[,A, QUIN'i A- CA 92753
LA QUIN rA CA. 92MA
(619)%4-0273 `
('. " V `7z C HLO 1955
41�- �0�9
USE OF PERMIT
5NCIL h` FA.t4l+1-.`4- DW4, 1INC41
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t ARA31iif. A,R1>t3fi'1' 1990) n1
.1'X i:\MI.Il J) CXXV3 M <,'t)N9.CRI!CT61_ N
_. 96,902.00 ;
+E'U NIIT IF'N.E80)M1MAR
m. NSTmrl -CIO•N rra, 10.14W-411.84.000 1.(►tJ
-
:4''.LAZd Cl:11':C1;. FET' !�1-!1tiE! �13t3 31.ti S491.37
s 0�
VGFa, 101V0181'd' 4250.00
ao—f1�:t+f1Iciv..,1-'1;r;
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1„i`:}AI"TWAB. FEES 101_00O.a420-wo. S12193
PL1~thik31Mi Wh f 100-001-111 91 -WO 27.50
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f0rid Ax f4.Cfc,"!' .wj;'1za 225.000A43-342 $1.9,1 3
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SUP 4MAL CONS'i101.00:16N AND PLA14 CHECK
'S8 RR -PAID FRES
`1'4J'$'AL PERMIT 0;l:$ DIJ K iV(MI
A
RECEIPT
DATE
BY `
DATE-FINALED
INSPECTOR
ti
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPR
VALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings A
Ducts -
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck 44
a
Exhaust Fans
O.K to Wrap
F.A.U.
FramingCompressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Unes
Party Wall Firewall
Exterior Lath 44
Drywall - Int. Lath
Final
Final
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 APPR
VALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
r
Shower Pans
O.K. for Finish Plaster
Sewer Lateral .
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
.SAL �� ��
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Final
Utility Notice (Gas) 17
ELECTRICAL PP OVALS
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)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 9/13/96
No. 14854
APN # 774-055-020
Jurisdiction La Quinta
Owner NameDavid Miller
No. 53-205 Street Eisenhower
City La Quinta zip 92253
Permit #
Log #
Study Area 111
Tract # Lot # Square Footage 1410
Type of Development Single Family Residence
Comments
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 1.84 X 1,410 or $2,594.40
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 Capital Bank of North County
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Ellen Patino
1 r "
Signature
Payment Received
Telephone
12;601.7.6
Check No. 4129
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
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 timeof issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For. the following:
BUILDING ADDRESS: 53-205 EISENHOWER DRIVE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9609-025
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: SR
Owner of Building: PACIFIC TRADES
Building Official
Address: P.O. BOX 722
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR
Date:" DECEMBER 5, 1996
POST IN A CONSPICUOUS PLACE