9910-163 (SFD)LICENSED CONTRACTOR DECLARATION
d herebyaf irm 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
�
'Date 4 ? Signature of Contractor,
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, foe 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:
Carrier VINIC- RY. INS 40 Policy No. I,� � ♦7,
X81 �,C� 11931-t�I rJ
(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; andagree that if I should become
subject to the workers' compensation -provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provlslons!�-;
Date: r Applicant-
"Warning:
pplicant
"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
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 insp�ec4tiQn-purposes.
/Signature (Owner/Agent) �_ + Date
BUILDING PERMIT PERM' # "44_163
DATE VALUATION i1�bi �r 2,All! LOT TRACT
f
JOB SITE 147 #05 Arf ���.�6� 1�E.��'� N A
APN 414 J, U°°N6
ADDRESS
OWNER
CONTRACTOR /DESIGNERENGINEER
r�AAIi
s1
"A"A yA awS,NE-0 t"
i ' -
,5 16 Brtt..9i0K EC'jL{X0W
ANTA ANf4 CA, ;'li!`i
:;A,N' A,.ANA C.'A, 92105
USE OF PERMIT
3�i5e.�r3, (> i,.ei.fe'IRA I A'Ltl,Zl�ac
ai'.b 4',0l , f-6 v. .Oi a
W AIA. 01t)4), AL J�LAN CM.,.C.K V'E ' ZEF).AAc,' 'I.( N 0,N iN411,
OF fiAt E PLAN TYPE-
i RA..w .)a R1/�. �1 °I.'°it°
i�F�lifi;'1�Js�lt'A,.t3D'tlfi'S' 6'��,tf1J .th
AI 'ISS: R6J8i"i..f ¢-+9�5,���A 4YS' 4. i_���dt��'�i��i: ��6-►�Y
R4J f,�e�V w�l��
PERMIT FULNU.N.M.ARY
CO t`EI 1011100*41M-OW
vtiyrt.igF t'i�°�Y�+iiu�.
7if(#t-/1(1t{{i��13-+��3?3-//�1�s�LLLQY'tof4
-SN5. St)
S>.13 a
b'LU&JIttNcy;f;t"E .1 O AM -419 Mif SIS4 6,1 ti
C`1 ►i f'' C MfVk"fC)tif W'73
01R A 1)RA F,, t -0Z? i1423_04> S; 21B,E
ART 12d * $11,
39-3!!i
YVEf.tl4't°J;31T (01-0 a,439-.318
ib#�,i't5 s•tk i�g+�t"t.' G'£'n'' �t +rtfY a�+
NOM ?`.t(
LE
TMMI I D•I+:R.�i, iT FE, Ws DQW, NOW
$3,525.41
RECEIPT
DATE
BY
D L
INSPECTOR
INSPECTION RECORD
OPERATION
F
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
Ducts
'
Slab Grade
Return Air
Steel _ _
Roof Deck
Combustion Air
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
1101,
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath
Drywall - Int. Lath
Final
Final
POOL - PAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping b
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Paris
OX for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test moi'
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
4
P.O. BOX 1504 APPLICATION ONLY
Building/ ,4 78-495 CALLE TAMPICO
Address t]700 k)1 0 ��nn�PS_a LA QUINTA, CALIFORNIA 92253
Owner s}
Mailing
Address
City Tel.
��aIlip,
��, —71U y�c�
Contractor
ress
State Lic. City
& Classif. ) �) 1 Lic. #
Arch., Engr., "'►
Designer I n A A th
Tel.
_ 4-(,U I*y,, I `1 0�'4� 3 1 Lic. a
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 cityor 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 rile 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).
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. 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.) '
11 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.)
1-1 1 am exempt under Sec. B. & 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
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 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.
Date Owner
NOTICE TO APPLICANT., It, atter 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 Address
This is a building permit when properly filled out, signed and validated, and is subject to
ex piration 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
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number `O 3 O
Co
,''y�y ( J •� 7
Legal Description f {.m � iE7 �,.-�- [- . : .i
Description
Sq. Ft. -2 No.
Size , Stories
NEW)(Add ❑ Alter ❑
Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal
Const.
Mech.
Electrical
PlumbingA.
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
No. Dw
Units
Repair 0;Z -_j
Demolition ❑
^,.•i
.rl
I
,• w
t
AMOUNT
ZONE: BY:
Minimum Setback Distances:
Front Setback:from Center Line
Rear Setback :Tom Rear Prop. Line
Side Street Setback from Center Line
Side Setback tom Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
I
WHITE = FINANCE YELLOW = APPLICANT PINK .= BUILDING DIVISION
Desert Sands Lt..:WWM'ff1strict
47 (950'Dune Palms Road
Notice: La Quinta, CA 92253 '
Document Cannot Be Duplicated ' 760-771-8515
c CERTIFICATE OF COMPLIANCE
Date 10/21/99 I APN # 643-120-006'.
No. .19492 ;r Jurisdiction La Quinta
Owner NameCanaday & Company Permit # 1 .
No, 47-600 Street Via MontessaLog #
City La Quinta +. Zip 92253 Study Area
Tract # Lot # 234 Square_Footage 3079
Type of Development Single Family Residence No. of Units 1
Comments Lake La Quinta
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 ID the following reason:
EXEMPTION NOT APPLICABLE ,
This certifies that school facility fees imposed pursuant to Government Code 530$0 in-the`amount of
1.93 X 3,079 or $ 5,942.47 • the property" listed above and thatliuildmg' ` }
permits and/or Certificates of Occupancy for this square footage in this proposed project may nb 3e issued- a al
Fees Paid By cc/13of A/Canaday & Company, Tele tone .771-9636
Name on the check 41, 4 t
By Dr Doris Wilson f
Superintendent ti
Fee collected /exempted by Juanita Green Payment Received $5,942.47 ,
' Check NO.' 2016297584
Signature., 0444
NOTICE: Pursuant of A embly 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 willbegin 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 Distria(s) or to another public entity authorized to
• collect them on the District('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
VC
OF THS
PUBLIC WORKS CLEARANCE LETTER
FOR
CUSTOM HOME LOTS '
Dear Builder:
Prior to issuance of a building permit, you will be required, to obtain clearance from the'
Public Works Department for one, or more, of the following: =
1. Verification that rough grading .is complete; and, the pad elevation certifications
prepared;by a licensed surveyor, or engineer; are ion„ filen the ,Public Works t�,f}�
i ,:, :.� k' ✓ ti t >';:I'` t : A" ^r vis*, I"'•>
+ •ia•,k < , • is r ,vi .z Li, r - r2gSr.:��•i`+`*-+c. .}4N+ t4 ,t7' {ti ,T 'F.,,� S`...,.r: " '�,`,. r-•
or
$fw.'s 'Znt'• . "-'{il,,{` a
4w}f^�w='' �1iR�x.'ro�.•...T'v: .3,• i,.j9�'n1T:A%F",S`.�"+4%+i.G"��L��K�•:'�J't'3 ".s.tw#'',,.: , .: . "�. a;.: �'Jr �F'�'" - . �f ,:!• ..
- ,,y.2.>;Venwfiicayt�on:pthata�nfrastructure„improvements:andotherrequired tractsirprovements,..
k.. '�• Y •�i.'.cMa '"yJ {•, �.KM.T.',w.,M:.N'r-iiif._i�:., •. �wRt.- �.t 3i, ) 'Y ?,. I y¢ y,,:yi y Yi,+ '�: 3` - i
�•� - � �•.,�� ,' mare complete, or:,sufficiently advanced tozwarrarat�bu�dir�g�permix�issu�nce��`t'};� •�x4�
- .r'. - •.4. `”, ' ,.. ,± �' r tin• , -, ;.,- ..w-o1w�y �' * �•yi',,,.-
3. Prepare an engineered grading plan that provides for on -lot storm'water retention,
and have it checked and approved by .the•Public Works Department : y ;"'
• _. .R �;< � ,^ '.,pry •
• • Tract 26524 (Estancias) ,.w
• - Tract 26769 (Mountain View Estates)
4. Prepare an engineered grading: plan -that provides forbuilding pad grading in
accordance with the existing,soils report and tract grading•plan; and have'it� {;
checked and approved,by the Public'Works Department.
' • Tract 28034.(South.Valley Estates)r : �x
r�
1 �
FOR INTERNAL USE BY PUBLIC WORKS DEPARTMENT
TRACT:
LOTS'.Z3`f3 ZEv�,
1 GTh' ZP , ZCQ Z-71 Zbz)- Z-? i.
PUBLIC WORKS AUTHORIZATION CYATEy
FAPWDEPT\DOCSIFORMSIPW CLEARANCE LETTER.ss