0303-270 (AR)of LICENSED CONTRACTOR DECLARATION
Iereby 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
674074
Date: /f Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the 2tractor'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
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
perf&rnance 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
Y '
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.ALiUN046-1332.2003
g (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)l should become
' subject to the workers' compensation -provisions of Section ,3700 of the Labor
Code, I shall for(hwith comply with those prov sions.
Date: /7- f Applica f t _—
Warning: Failure to secure Workers' Compensation coverage is unl l"ul 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, in and attorney's fees,
IMPORTANT Application is hereby made to the Director of Building and Safety
1 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
6Q, & 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.
jI certify that I have read this application and state that the above information is
I correct. I agree to comply with all City, and State laws relating to the building
1 construction, and hereby authorize representatives of this City to enter upon
I the above-mentioned propeRy for1inspecti. n purposes.
Signature (Owner/Agent) ;°� rDate •�r
710
-G
BUILDING PERMIT PERMIT#
I3LI;XV10
DATE VALUATION $w, 7ku LOT 21
TRACT �9283
u'idr .0
) I _1 I 11
JOB SITE' `
APN
ADDRESS9a2'j'� 1<AJ �).119=fAT)Ort
60-21"157
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PO 7.3OX 1716
79.295 RA.140140.I-Js, Q�UU,'i'1'A D-IZ,
LA, QUINTA CA 92253
t A Q+�WTA CA 92253
C160)771 -194b CRUD 29%
USE OF PERMIT
A I)Vf'I'di4t �QP 30 Sg'ti HT1, w 1.41151±iF'f. CONST3i UCTIaN t
CUSTahl Ct; MTRUCTICY3 90,00 9F
PERK=1l OR MMAR '
PLAN CHICF99 101 -OW -439-318 TM i I?
C0N 5 i`:I TJCT140N :SSE 101-000-418•-000
STR.i71`i'C!.I!!U'i<1014 f:ESa € ESID I01--000-241.000 S.Stt
I
G ifC `IIL3I JWD PI" CiMOK
V 24.60
D e 1X&9 PRE,%PAID ;HEM
$0,00
0 7 2003. . ; PIMMFR'S DDT : NOW
5124,60
APR
OF LA QUINTA, •I
CITY
.FINANCE DEPT. '
RECEIPT:
DATE
BY
DATE FINALED
INSPECTOR
-
f
- e3
INSPECTION RECORD -
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
g
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
ZElectric
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
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
CERTIFICATE OF COMPLIANCE Jc
w Desert Sands .Unified School District 4�eyo
47950 Dune Palms Road -
- Q BERMUDA DUNES 0
Date 4/1/03 : La Quinta,•CA 92253. RANCHO MIRAGE Cf
No. 24267 (760) 771-8515 ��
INDIAN DESERT ti
PALM DESERT .y
LA QUINTA
INDIO
Owner TD Desert Development APN # 649-210-067
Address P O Box 1716 Jurisdiction . Indian Wells
City La Quinta. Zip 92253 Permit # 0303-270
Tract # 29283 Study Area.
Type New Residential Addition No. of Units 1
Lot # No. Street S.F. ` 4 a Lot # No. Street S.F.
Unit 1 21 49271 Via Conquistador 30 Unit 6
Unit 2 Unit 7 '
Unit 3 t Unit 8
Unit 4 - Unit 9 +
Units F'
., 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 30 S.F. or $64.20 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/Palm Desert'National Bank - Judy Halpain Check,No. 085181
Name on the check r Telephone 760/771-1941
w Funding ,Residential
By Dr. Doris Wilson
Superintendent a ,
Fee collected /exempted by Sharon MCGilvrey $64.20
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