9709-070 (SFD)LICENSED CONTRACTOR DECLARATION
,:I "h&eby. affirm under penalty of peUury that I am licensed under provisions of
Chapt.iir_ 9 (commencing with Section 7000) of Division 3 of the Business Bnd',.
Profes-sionals Codeand'niy' License is in full force and effect. ..
License # N, Lic. Class Exp. Date
/Date 0 ctor—
ignature of Contra 4.,
_777 T_
OWNER -BUILDER Df" elION,
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: . I
(, ) 1, 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; 7444, L3v.si.ness$� PrQf@,55ionals Code).
1, 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
performance of the work for which this permit is issued.
1 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 ho. are:
Carver Policy No.
It co S
14 179
4(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 and agree that if I should become
/subject to the workers' compensatiop
, J� O�io S of S dt, 6700 of 6eLabo
Code/b/Va "67th comply with,, vi i0pis,
10/1
Datel. or r Applicant California,gvzc
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject_ an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of.the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby made to the Director of Building and Safety
.for a.. permit. subject to -.the conditions and restrictions set,forth on,his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work -is not commenced within' 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and. state that the above information is
cvect. I agree to comply with all City, and State law s relating to the building
Instruction, and hereby authorize re'�peof this City to enter upon'
I'$ r presentative
ie above mentioned property�for/Kl� . 10 11 6s:!
r
e
"Signature (Owner Agent)
)S' W10
r�v
7
PERMIT# CONTROL#4 -fir s
PERMIT_
,BUILDING %
1709-400 -60,31'.
, 4 -
DATE VALUATION .19150.647.441: LOT. 142? TRACT
JOB SITE
ADDRESS IN -9533 V;AY1,,0Rk:4NC.F- JAPN
454 10*025
OWNER x
CONTRACTOR DESIGNER / ENGINEER
0 A'00 A 0* AV Cr1A I 1S A NJ V
A Vt I'VO, 10 A't CV
151KI, i"I'T 209
13
SANTA N iv CA 9'27P5
-ANT.A ANA. (�';A. 92705
S
,i1..
4
f
USE OF PERMIT
FOR kd"OU11014 11%SUAxNCF 01" *AW PLAN TVK.';
4
11?aA. 1, X�+431TZSJCI-VAN 44,28.00 SF
PMCWYArk) i i 3f
QARAQT-YCA9P0Kf .11V
^ ;
_� ,V
COST :DF (:'0MVF;V(XT10-N.
R. X
C0'NS1R0e;1_K)N FEE
'PLA -14 C 161 CK FP�E,' t79f,3
50-W
AU—'V ICAL FFM 101 -WO -420-000
FKNI -ow
101 -'b6-6 4213 -OKI
INFAS'1'UrM.hV8V 42
6-
.,yr j
;,,qf ffl.rly Kil qX)MT, NVibTfON YVN`P NA -1-1 CK
75/82
4750,01,
8 1997
T01" -Al. \117
bf-� 00;i N T A
"Mp
RECEIPT
DATE
ByINSPECTOR
INSPECTION RECORD
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
// 4
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D - Int. La&> lIZZ043
i
Final
Final
KWALL APPROVALS
POO - PAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
/6±L2
Gas Piping
PLUMBING A PROVALS
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
G+.
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final n,
Utility Notice (Perm)
COMMENTS:
it�g/IyDD�L�'C�/�fivy�eT�il1./YrT�
rw,t •'vT . � �-e ;� ♦ Y ^1� r te., a 4 7 4» " t sit e \ xr.
u}
gr7D q - 0-70
P.O. BOX 1504 ' APPLICATION ONLY
Buildingc ` / 78-495 CALLE TAMPICO
AddressW— 7 a0 V14 IF/Or �w ec IA QUINTA, CALIFORNIA 92253
Owner
Mailing
BUILDING: TYPE'CONST. OCC. GRP.
/- �1
Address/5-10 ,00 (� O Ako I V e a 08 A.P. Number `/�
i-3 X110 — Q Zi
City �Q JZ�0-70
Tell//C�_44 � T (A�` � R7 N / ® Legal Description �6� ��� � � r. L� �i<•, q
Contractor d �Project Description I LOT 22f3 11'x(3. 227 O77 TR 2(ofS2
e-4 A 9k C •. Oii. �0 6 M V
Address, rr
6�c
City Zip el.
7P077/ 96 5 (o
State LicCity
& Classit A 55151401 6 Lic. # ya
Arch., Engr.,
Designer Mi'lv` eA Orth+
Address Tel.
�D. �ox 7603d i 074&
Cn 9• SA State
JZ'%2c2dl�o
Lic. #i 7
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after. Improve, demolish, or repair any structure, prior to its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (8500).
1.: 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended�or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
1'1 I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
I am exempt under Sec. B. & P.C. for this reason
1
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of ih0 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.
Date aOwner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to -comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
' Mailing Address
City, State, Zip
Sq. Ft. No.
Size Stories
New ❑ Add ❑ Alter ❑
Estlmate0 valuation
No. Dw.
Units
Repair ❑ Demolition ❑
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback fron Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Per
Validated by:
Validation: , A7
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION ®� `J ��m
• i Desert Sands .Unified School District
82-879 Highway 111
Notice:
Indio, CA 92201
Document Cannot Be Duplicated
619-775-3500
} CERTIFICATE OF COMPLIANCE -
Date 10/21/97 APN# -643-110-029 ;
No. 16191 V Jurisdiction La Quinta ..
Owner NameCanaday & Company " Permit #
i. r s ,
No, 78-950 Street Via Florence Log # .
City 'La Quinta _ Zip 92253 Study Area
Tract # Lot # - Square Footage 2628
Type of Development Single Family'Residence Noa 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 mobilehorlies. .
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 2,628 or $ 4,835.52 the property'listed above and that (building
permits and/or Certificates of Occupancy for this square footage in this pr6posed project may now be issuedT ,
Fees Paid By Cashier's Check/Pacific National Bank - - Telephone 714-751-91'5 1
Name on the check,
ByDr. Doris Wilson
'
Superintendent -4.` icy(
Fee collected /exempted by Ellen Patino t F Payment Received
Check No. 73098
Signature
NOTICE: 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
above will begin to run from the dale on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or toanother public entity authorized to*.
tolled them on the Distrid('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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HEATING AND AIR CONDITIONING DIVISION
May 19, 1997
..Canadav
1570 Brookhollow Drive
Suite 208
San.ta Ana, CA
Attn: City of La Qvinta - Building & Safety Department
R.C.R. Plurn.b.in-,, Inc. - HVAC Division, certi.f'ies . that the heating an.d air conditioning
equiptilent. separating fuinace and coil, can be inserted and/or removed through an attic access
openinc, with the dimensions of'22" by 30"..
If you have any questions, or need additional clarification, p).ease give me a call.
Brad Ttlnby
Sales Engineer
R.C.R. Plumbing
HVAC Division
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