9701-058 (SFD)LICENSED CONTRACTOR DECLARATION
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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Ezp, Date
/Datef Signature of ContractoA JJ
9 .
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:
( ) 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
Sectfon 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 Policy No.
UNIC,'iRTdia NS (70
(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 w kers' compensation{ irovisions of Section 3700`'f the Labor
,�ode,�h I jgrt . 'th comply with th6 �, pro1visiol�s
//Date: � Applicant V(�{.J
Warning: Failure to secure Workers' Compensation coverage is unla ul and
shell subject ai i ewipluyw lU cilndnal perlallles and dvll fines up to $108,008, hl
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 art,
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, inderrinify.
& 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
correct. I agree to comply with 0�11 City, and State laws relating to the building
construction, and hereby authdFize represe tatives of his City to enter upon
the -above-mentioned propert�ir inspectio purpose
Signature (Owner/Agent ✓ Date �v! ,
BUILDING PERMIT PERMIT# CONTROL#
�'�+ 4-4 4829
DATE VALUATION LOT TRACT
ssa.9t 7 t.4;,6a .z ? «� y�
JOB SITE
ADDRESS 4'75" VI 1t'IOi.�I`tIGO
APN ___ [[[
. 643-120-01/1
/
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CAtelr' DAYt,;. Ct)MPA1`iY
CKN4WAY & C 01MIRAN Y'
I �f3 ��}t(-J� t#l11 i t.►14" IJi� t .l. f1Ci"i: ii�t
1370 BCCOUi1.HOLLOW DRIVE, su m 2w
SANT TA ANA 41A OPM
&AN�if'A ANA CA.
(972705
USE OF PERMIT
0b
t Ery • 111JWi 1.0tJkb N01 tMliAk 8L<1(;tti WALLS OR PC A�
TR A("I' '()T4,1 11 "T'101i Z5 71I,Ckl Sly
lKyttt'[;i'f�liiJ ;3o'U.(lU SF'
QAkA(:l1l(-`AkP0_R'!' 610,00 SF
is''�1,11 M AT.:13 C T O (J)NS'i',RUC e 10;>
3 s ;��I;4_,; 21)
p� y r E t y y q,y ,�,j{
PiVIRMT i 7I'YII i i7l:iA��l�1t,R
R'1 AN CHF*CK. OT, !01-000.430-31R g rf1S.ti�
-3,aAOL)
Mi'CHANWAl. lPN;d: It614JO-421-00)
1A,RMC'R IC'AL FEF 1,01 -CIM -4.70 -WO S171179
. 4tiC:K`sldL tv[O,T1014 14X3 1ZCs!.IIIy 1.111. -000.211 -Wo
(3ttAt) IN0 Ffl.- tir1-(}a` 421-000
I NFRA 'T'RUC `ORE h LE 225-000-443-342 $3.4:13:79
V1RFc•TSF P1.A:N - 101. -WO -441.1,45 §�s tin
iVt'I' IId PL44AC P.L.A(`Ft4 Mir 55-oon S14.1.611
i,e3SITP.�RiI)FE s
X0.(111 ..
MAR 19 1997
'—
)OTALP1kRMIIT NOW
$51i3ltx
A
RECEIPT
DATE
BY
DATE FINALED
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
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
POOLS - SPAS
BLOCKWALL P VALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
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)
P.O. BOX 1504. APPLICATION ONLY
Building y V SCO h }/7 O 7&105 CALLE ESTADO
LA Q
Address / 5 UINTA, CALIFORNIA 92253
Owner
Mailing
! �O C
/ / nr O
Address �S70 �rva�{ho��ry'✓S�
City Zip � FTe7.v5y 7s :/ W /
Contractors
Address S % 44 �9v J -/,- � U�
City_ 1/ rip�d7o,__ Tel..__34 ,7"< 014 S %/V 7� / 91s/
State
fCty
Lic.&Cs. <A 6
#
Arch.; Engr., n
Designer /� S ,N 51 /Ji)/ h (r s v�
Address // ( �/?State�3
7 S / E�j,U �1 �1 17 1City // Zip ,/�1h,� t H I 9�; 6 #i < 5� �%7
ICENSED 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, alter, 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 ($500).
17 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.)
Ill 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 contractor(s) licensed pursuant to the Contractor's License Law.)
17 1 am exempt under Sec. B. R P.C. for this reason
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
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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 Owner
NOTICE TO APPLICANT: If, after .making this Certificate o1._ 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 . revokedI
f 2
CONSTRUCTION LENDING AGENCYr� J
I hereby affirm that there is a construction lending agency for the performance ofihe
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name 1 /
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.
1 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
BUILDING DIVISION
3UILDING: TYPE CONST. OCC. GRP.
4.P. Number t
_egal Description L C �d S 1�
3roject Description L 14 '°r /' r Z c rX v
Sq. Ft. c2 5 7 L , Mo. No. Dw. .
Size / ! stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
NN
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. s-0' roc.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
r
1
{
TOTAL
REMARKS
ZONE: Ry:
MIn mum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line.
Side Street Setback from Center Line
Rld dE Setback from Property Line
FINAL DATE INSPECTOR
Issued by `y 1 Date Permit
trjQU►rA
Validation:J A
r
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING F&S
IST FL. SO. FT. 0 $
2ND FL. SO. FT.
POR. SO. FT. CC
GAR. ISO. FT.
CAR P. SQ. FT. 0
WALL SO. FT. @
SO. FT. @
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
ROUGH PLUMB.
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GAS (ROUGH)
LAUNDRYTRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. pct' c
BATH TUB
BOND BEAM
SQ. FT. p c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1 V. c
SEWAGE DISPOSAL
LUMBER GR.
SO.FT.GAR @ 3/ac
HOUSE SEWER
FRAMING
FINAL INSP.
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
t
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES11NITIALS
GARDEN WALL FINAL
.
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
1 CERTIFICATE OF COMPLIANCE • ,
Date 3/19/97 APN #' 643-120-022
No. 15351 • Jurisdiction La Quinta
Owner Name Canady & Company Permit #
N0.47590 Street Via Montigo Log # '
City La Quinta Zip 92253 Study Area '123
Tract # 26152,. a Lot # 250 ; Square Footage 2574
Type of Development Single Family Residence' No. of Units 1
Comments
At the present time, the Desert Sands Unified School. District doe's "not collect flees 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 2,574 or $ 4,736.16 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed proj';ct Indy now be issued
Fees Paid By cc/Pacific National Bank/Canaday & Company Tele hone` -714 75'1=9151
P 01;
Name on the check , s; F..,,, ir'•
By Dr. Carol McGrew y ,, . 4'. ;.tyt t
v
Administrator in Charge
Fee collected /exempted by Pauline Pearson Payment Received $4,736.16
t - Check No. 6.5911
Signature
aa—
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -lay approval period in whici you may protest the fees or other payment identified
3ove will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
)llect them on the Dislrict('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/Receilit Copy - Accounting