0209-159 (AR)LICENSED CONTRACTOR DECLARATION
`*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
P, Inc
/Dae % ?Q12 ®SiIg ature of Contractor � i .. /
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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 reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: a
() 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. r
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"'i'A'?.I<, ITUND Policy No. ?t .f�A� 4►?d
(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 provisiofls of Section. 3700 of the Labor
Code, I s��halj�forth ith comply with thos �ovisior�s�°
date: .17r0 12-ry:A Plicant �,�ol r.., ,
Warning Failure to secure Workers" 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. y
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 appiicaton 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
pgrmit,.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.jnspeect�R'pu`rposes.
,Signature (Owner/Agentt�_", / Dat ' f ^7
BUILDING PERMIT PERMIT#
/� TRACT E
DATE )J VALUATION. j eS q LOT 640
P l�j ,d����r°'•)f: �bAly d .wicl!' 10 28640
J013 SITE X
ADDRESS 7.9.11!5 V-14, CORTA �
APN 649-460-012
OWNER
CONTRACTOR/DESIGNER/ENGINEER.
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A-2-935 YURGUZAVE,
.i.,E`1., Qi, INTA Qk Q2 ,53
111W i". 3VIiUM Oli 02211
(760)862-5+M CMIX
USE OF PERMIT
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500, S.F. OFFICE CART 0A 01? PER .A,PPROVY014,A, .5V5 PUC`r
CUUTOM CONS9'Ri1CUOkd =,010 8
we SUIAMRY
CIONST RUC')10"N M 191 -OW -416^000 $ 4%N
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ZvXONOMO1"JONx FEE-RBSI'W -000,-2.41 -"•
p -mg& : COQ ` RTJI?X10W JkWrD PPM MCS
$444,95
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x'+0.00
Nov 2 U Zuo- f:a: �E M SIT , ESS DIE NOW
S444M
CITY OF LA QUINTA:
FI CE DEPT.
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
J - .,
Ducts y
Slab Grade
Return Air
Steel
Z
Combustion Air
Roof Deck
JZ— a L
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
- d L
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 ,2�- 3
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
i
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:
CERTIFICATE OF COMPLIANCE c
Desert Sands Unified School District z4� 0
47950 Dune Palms Road Q BERMUDA DUNES r
Date 11/20/02 La Quetta, CA 92253 rn RANCHO MIRAGE (�
INDIAN WELLS
No.. 23880 (760) 771-8515 d,�^^P LA QUINT �y
INDIO
Owner George MacDonald APN # 649-460-012
Address 79115 Via Corta Jurisdiction La Quinta
City La Quinta Zip 92253 Permit #
Tract # Study Area
Type Residential Addition No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 50 x'"79 `.V.ia=Corta 225 Unit 6
Unit 2 115 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit b 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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $0.00 X 225 S.F. or $0.00 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 EXEMPT - Mike Heart Check No. -
Name on the check Telephone 760/862-5975
Funding Exempt
By Dr. Doris Wilson
Superintendent
Fee collected/exempted by Monica Guillen
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 De partment/Applicant Copy - Applicant/Receipt Copy Accounting
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