9511-055 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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 QCs _ Exp. Date 9/30/95' T
Date ?A 1 r' Signatureof Contractor- T)x%
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law r the
following reason:.
( ) [_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
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:
CarrierPolicy No.
(This sectioh`n�e ^n'o"t be completed if the permit valuation -1iir066.00 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 provisions of Section 3700 of -the Labor .
Code, I shall forthwith complywit� ose provisions.
Rate:APpiicante h fi�,,.AA,:��-� C.'I 44e��.iS'y
Warning: Failure to secure Workers' Compensation coverage is unlSwfGl 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,
fur a pumila subject to Me_ uundllluris grid iesh ictions yet loiffi .;i•i 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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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
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.
k
r
S'�riature , (Owner/Agent) r< DaDe
A`°'
BUILDING PERMIT
PERM'T��-��5
,DATE �������,
VALUATION ��,7.�Q LOT 21
TRACT 26152
JOB SITE ADDRESS _
APN
47-565 VIA MON TIGO
643-120428
OWNER "^ �V
CONTRACTOR
ft(A�..sUkf CONSTRUCTION
LANDAU DEVEi OPNIKINn' CO I NC•
-. 925 TARQUIn C1kNYt 1,J' #D1
P.O. BOX 1725
PALM SPRINGS Cil 9226-1
LA QUCN"TA, CA CA 92253. '.
(X510 i328.2277 CAT.# 3187
I)ESIGWIVENGINeER .
i
(619)324-J470
USE OF PERmtINGLEFAMI L,YDWE'.),+.j,.ING
$170' t'1'f3tMIT VOFS NaF fNCLYJDE BLOCK WAI,I.S 0R,1:OOL.
FEE DESCRIPTION
FEES
TR(�t':TCG1l�i3'l1tUCIOTI 3.313.00 SE
Pt7Rt✓i� ;'A'1'10 428.008F
GAI7AGFJCA1tP0RT 636.00 8F
ESTi.NIN ) CQVr OF CQ NS`nR1 CTION
20..1,97:$ 90
V gt:Ri! ET rit,19 I;Z7ldiMI.&ky
PLAN CHECK. FEE 101.=000439.31.5 $832.36'
CONS'TRUC71ON F EE 101-000-418--400 $926.50
MECHANI Ai.VEE 101-000-421-440 $li1.s�0
U-1'p'CTR(CAL FEE 101r004424-444 $203.18
Prluman4c) FEE 10:1 040--4,1.9-(X)4 $162.75
STONO f1I4710X i•'EE - RESID ' 100-000-24.1.-000. $20.20
GRApiNG FEC 520,00
JW ASTRt1CTIW, F1311"s 225-404.443-342 $4,416.33
.
PRECIM, ]PLAN 1014)(10441-345 52.5.0
.ART IN I_'UM.11Z FLACE-S - .F.tESTI 701-040-25ti-004 $254.93
FEira. fl tLi 1Si i' 4250.00
SUB -TOTAL CONSTRUCTION E1N13 PLAN CHECK
$7,444.75
LESS :PRE -PAID PEPS
. 0TAG`.T'EZdMI`i! VE 05 DUF, NOW
-$!250.40
S6,7%.75
pEC 1..5
1995
RECEIPT
DATE
BY . ,
DATE FlNALED
INSPECTOR
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 1.2 41L
F.A.U.
Framing
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 9 0
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
'82-879 Highway 111
' Notice: '
' Document Cannot Be Duplicated Indio, CA 92201
619-775-3500 '
s
CERTIFICATE OF COMPLIANCE
Date " 12/14/95","N # , 643-120-028-6
No. 13966 Jurisdiction L
_ a Qui -ata ,
Owner'NameLandau Dev. Co., Inc. 'Permit #
No. 47565 Street Via Montigo "g �#
City La Quinta zip 92253 Study Area 123
` Tract # 26.152 Lot # 256 Square Footage 3372
Type of Development Single Family Residence • . No. of Units 1
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 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 1.72 X 3,372 or $5,799.84
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 Imperial Sun Construction Inc.phone • Q t
,Tele ' F328 2277
Name on the checkC'73'CW
t'
t'
By Dolores A. Ballesteros
Superintendent •�! 4 ; , .
tf
Fee collected /exempted by Pauline Pearson Payment Received $5,799.84
- Pft'l
Check No.. 14427
Signature t POnA0 4 Ai AA AIL
Collector: Attach a cony of county or city clan check application form to district copy for .all waivers. •