9709-069 (SFD)'LICENSED CONTRACTOR DECLARATION
I k6ieby affirm under penaltyi.of perjury that I am licensed under provisions of
Chapt6r 9. (commencing with ,Section 7000) of. Division 3 of the Businegs and
Prote"s'sionals Code, and my'LiceF)se is in.full force and effect.
License # Lic. Class f Exp. Date
'Signature of Contractor T.
/Date ,
OWNER -BUILDER DETLARATI.ON
J hereby affirm under penalty of perjury that I am,,exempt from the Contractor's
License Law for. the following reason:
1, as owner of the property, or my.employdes with. wages as their sole
compensation, will do the work, and the structure -is not intended or -offered for
sale (Sec. 7044, Business & Prof essionals'Code).
1, as owner of the property, am exclusively contracting. with licensed
contractors to construct the project i.(§e6. 7044, Business & Professionals
Code).,. -
O ' � S
I am exempt unde ectionB&P.C. for this, reason
Date 't Signature 'of Owner
WORKER'S, COMPENSATION DECLARATION
I hereby. -affirm 'under pe_nalty�W 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
Sebfton 37o0 of the L6bor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
J, A A",
(This, section need not be completed if the permit Valuation is for $100.00 orless).,*:i'�'
O 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
0"6hoVu become
workers' compensation 0. oyJgTqns f SeQ (KO iX
workers' compensation laws of'California?and'aajeie that
s6bject-to the worke, 14700 f the Labor'
ode/1 h comply with th isiVh�
e 2' .
ate:/ Applicant77,�/�t 0,
. Ir / - . '/ -_ - ..
Warning: Failure to secure Compensation coverage is unlawful.and
shall subject an employer to =pen penalties and civil fines up t6,$1100,000, 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 alpermit subject to the conditions - and restrictions set Jorth. on his?
application.
1. Each person upon whose behalf this application is made& eacherson 9t
p .
wh6se request and for whose benefit work is performed Under or pursuani,lo
any permit issued as,a result of this applid�ton agrees to,, &'shall,,indemnify
..
& hold harmless the City of La Quinta,, its officers, agents and employees.
2. Any permit issued as dresUlt of this application becomes: null land 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. -
lCertify that I have read this application and state that.the
the above information is
correct. I'agree:to comply with all, City,= and State laws relating to the building
C
nl
struction, and hereby authorizerepres?
nta ves o4f1td
is City to enter. upon
e above-mentioned property foril n prposeq�
Signature
(Owner/Agent) batA��/_O
PERMIT # :*- ' CONTROL#
-BUILDINGPERMIT. -
6.030.
DATE VALUATION. JA'7.,�So LOT,.. TRACT 2.6 1
JOB SITE'
ADDRESS
APN
J
OWNER
CONTRACTOR DESIGNER ENGINEER.
Y4, N
1NA 0 AXWOMXY
1 -70 B 0 rVE .209
15170 81ROI
CA 92705
CIA. 92,1105
51 441%
USE OF PERMIT
SH) - PRIV4F DO n-, 'NOT MCLUP13 UF110NXL
B,L(>C,K Oft ?00t -i
PC,,RC' ATTO SF
..w
'41ST"N'U""'Zo con asr .0-N6-5" 10,
vc
k E RM F_Celi� .17UNMAJIV
1_`0t45T1KLYCTf47K 17r -X
91-900 -4 3''� �Ql 18
U(?ii-L2, 11 o
MulerKR"um, 1.01 -WO -420-
w? $15s
$3.492.:12 J
T " -4
sA J. 4 12
ONFIM `I A
0*
LESS T�fdl PE IT
4750,OQ
1 W
OCT 2 8-ig97.'3611-1E NO"
RECEIPT
DATE
BY f
DATE FINALED.
JINSPECTOR
Y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing //
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
P irewall
(Exterior—Latii
Drywall - Int. LathVOW
Final
FinalZMM.POOLS
BLOCKWALL APPROV LS
- SPAS
SteeL>
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPRO ALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection i
Encapsulation
Gas Piping
Gas Test t
Appliances
Final
Final
Utility Notice (Gas) +
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
*-v
//
-
t �^- �,r^<,�.... .yu. -.ry ..-•" S�v'��•v qr��"�.-�;,YK 7t t '� ��e �i �svb,,��� ..ay r .� L
\I\r, +'f, � 7 r •Y i '"7'-43 ,�yiX (/v�J,—.IrJe i lit/}�5!'i�Jl$l/���, i♦b"t%i' , �'"
01
P.O. BOX 1504 APPLICATION ONLY
Building %_//� ,'/p� / 78-495 CALLE TAMPICO
Address / &O o V A /i►Op f r I ✓ LA OUINTA, CALIFORNIA 92253
Lawn r7
.G K4 e d 0,194
Mailing
Address /s- v �poo� 'Zocit
54 ^ I� Aa� Z a 70t;
Contractor% �^
(r e, N e.. 1 01
Address
BUILDING: TYPE'CONST. OCC. GRP.
w �Y' �rr o�00 A.P. Number %9'S -/1 2-0 — 821 2Z_-2_ ( _15 Z
Legal Description
Tel. . ✓L a7 d dl 9 14lee Zx 6L,'A,
Project Description IST' 2 I MQi -2-2-1 �-I-7 T2-&G-Z_%f6 t:
L;ny ctp I e1..
70 77/ UP 3 G
State Lice 5/ S6 1 03 City yy�
& Classif Lic. q
Arch., Engr.,
Designer �� < Ax f, Pt DZ 4
Address / 5100 Tel.
�0. 7� 3� 9 076
City �J. s. Zip��a�%® Lictk 7
LICENSED CONTRACTOR'S DECLARATION
1 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 )ive'hundred dollars ($500).
C-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'I 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 anowner, 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.)
i] 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)' valuation
or less.)
I certify that in the performance of lhF 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 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 _
I 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
ame
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 aQplicant - Date
Mailing Address
City, State, Zip
ZONE: BY:
Minimum Setback Distances:
Front Seback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE i INSPECTOR
Issued by: DatePilmiff
Validated by: _
Validation:
I
WHITE = FINANCE YELLOW = APPLICANT
_ I
CI r l OFLAOIJI TA
PINK = BUILDING DIVISION
,b
Sq. Ft. No.
Size ' Stories
No. Dw.
Units
New ❑ Add ❑ A:ter ❑
Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
75 n. Q8�
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Seback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE i INSPECTOR
Issued by: DatePilmiff
Validated by: _
Validation:
I
WHITE = FINANCE YELLOW = APPLICANT
_ I
CI r l OFLAOIJI TA
PINK = BUILDING DIVISION
,b
L� 2�`1 M3 227���'7 '('2 2fois2
4 3
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500 -
CERTIFICATE OF COMPLIANCE
Date 10/21/97 APN # 643-120-021
No-. 16190 Jurisdiction La Quinta
Owner NameCanaday & Company Permit #'
No. -47-620 Street Via Montigo Log #
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 2628
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 .
1.84 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 proposed project may now be issued
Fees Paid By Cashier's Check/Pacific National bank Telephone ;7`1`4 51 9h51
+ t
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Ellen Patino Payment Received 5483552
Check No. 73098 t
Signature G�
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 date on which the building or installation permit for this project is sssued or on which they are paid to the Disfucl(s) or to another public entity authorized to
tolled them on the Districl('s)(s') behalf, whichever is earlier.
Collector: Attach a copyof county or city plan check application form_ to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
V9` 15-1997 9: 19PM FROM CANADAY COMPAN'r" 7 1 d 751 x=11 S2
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FOR A VALUARU COp49C*RP1n CW- MCOV Of wn1En 11 MOMvY ocknowie<ged,
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