9607-087 (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 #.w Lic. Class Exp. Date ;3
15,7
Date Signature Signature of Contractorr�r�A /Y )�..•
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit isiissued! Vly4workers' compensation insurance caARRN&policy no. are:
Carrier Policy No.
,(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 workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with -those provisions.
Date: - aK. E?, Applicant—(
Warning: Failure to secure Workers' Compensation covera Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days -will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
1
Signature (Owner/Agent), t t� Date 7
BUILDING PERMIT PERMITj�,,►�'oo CONTROL#
4 Z T 0
DATE VALUATION J.�h :�fi LOT' TRACT .
JOB SITE 47-645 V L -k fiviONTii:SNA
APN 64.D -A. AT+0_0J:A
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
p r� t
t e1 hfY'f�fi �'�.0%�571�.4.i4)1,�ii
s.eraiH i.2 t.J v.E.: ... d e..
}
if"J','I.btu.4i�.F
P.0- BOX 1 1-i
29e3` 'tilii is`I"i'l CAN YON iiL).`t
tits"?'��2277 r;i3T,�' ;IJfi-r
USE OF PERMIT
iN�pt,(a 3 LY DW.17GJ.t•NO
N f)•PEs)L14irr L1ULS NOT TNCLUi')N.� `1ICOCK WALL OR, POOL,
14&W.Sp
f�cai����.Cqq(tp((A'3f���yy��{{��
<:/-iRAG,fi.'t-.A�E.C-1 P:(' S7ltf EJV •,i.'
CONT C° k' C''t'3'.tW'SI'9,:RUC'.tii)N
166,ZA82.60
�iy.''.�1:'i`M..a1TED
4 4a�lA9t'f't`�t I( q"t��J�yN�F U O :Y$�i)'K(i)
7101-f()�00-41i/2-(yM
1'. f.ANw+f1riiCfriPTG. S.V�`L{hT'4 1 �1�i7 $Tlil,21
F'8"E .1 POSIT _$230.00
Mk(J1AN1 ,AL I'=EEE? $11,1. 0
110.0E"'t tUCAT. WE, 1.01-00Q-4?2 0, 00 S180.69
PLM. "PINCI F .1 Iii?- 3 ?11 ►�fl $3$_M.flti
-.�.
S'iU:ivti idf RESE3 $1)1Fii�i43-2• i {ifffJ $i6.tii
4JfY,AL IN0 VPT !4)I frti(1-4: 0-04)0 5Zi):0(o
225,40,W 43-342 Si3.71�?.dW
NIRT I.),' i?'OMW PLACJ 3 - RZESIV 701-1000.255_" $1G5 "1
S1.II3•'1`U!Ai.. CONISIT(1( rIO AND PT..t;N (,: TIECK
S6,006.75
. LESS I?RE-1: AIT) FEE a
4250.00
O '
NOVO 1 1996
._
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.
F
Compressor
Insulation
Vents
[rep ace P. L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
' ewall
Drywall - Int. Lath
Final
Final Z
BLOCKWALL APPROVA S
POOLS - 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 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 '
as Test
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:
wav
4.4
P.O. BOX 1504 APPLICATION ONLY
Building // I� y rn AA r 7&105 CALLS CALIFORNIAESTAD9
Address �'f / � � (a /�// 0 LA• QUINTA, ORNIA 92253
Owner -
44AdJ,1 V 0 if � �� T vc BUILDING: TYPE CONST. - - OCC. GRP'
Mailing / ^�
Address �� l r2 A.P. Number (� P' w�/ ®% 3 —,A
C'itry 1,1� t Zip Tel. h o 1 �41,i /AAL
f /�! �� /(� f A 0 3 I/ Legal Description
Contractor
Project Description
_4"V io,,A( A l Saw Oows+ -17A/r
Addre s.
v�n�'��
el
16141a (7/>�I! �i5/ ZiPC/2 3 T7 77 i 3
State Lic. / City
& Classif. '17 to CP Lic. # K 7
Arch., Engr.
Designer � l
Address n Tel.
O � iso Sao Jal
City Zip State,p pry
%PAID► a a 3 Lic. #(r �p� ! /
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, 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).
I;' 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 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.)
I'] I 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
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 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
wclk 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
BUILDING DIVISION
ZONE:
BY:
Minimum Setback Distances:
Sq. Ft. No.
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑
Repair ❑ Demolition ❑
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
1.
Date
Qri
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Validation:`HIM
Plan Chk. Bal. ✓
Const.
gy
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
14
TOTAL
REMARKS
ZONE:
BY:
Minimum Setback Distances:
Front SetbECk from Center Line
Rear Setba.:;k from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date
Qri
Validated by:
t
Validation:`HIM
2
gy
CONSTRUCTIONESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIN xC"rEES
IST FL. SO. FT. n $
2ND FL. SO. FT. (E?
POR. SQ. FT. @
GAR. SQ. FT. @
CAR P. SQ. FT.
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
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP.IEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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. c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID p 114 c
SEWAGE DISPOSAL
SQ.FT.GAR 3/<c
HOUSE SEWER
REMARKS:
VENTILATION
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 APP.IEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu yd
g plus xg
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
t,; Desert Sand"
Notice: 824
Document Cannot Be Duplicated 4
Date 11/1/96
Unified School District
'9 Highway 111
lio, CA 92201 .
19-775-3500
TE OF COMPLIANCE
APN :4 643-120-013
No. 14975
t' Jurisdiction La Quinta
Owner NameLandua Development Corp. Permit #
No. 47-645 Street Via Montessa Log # 9607-087
City La Quinta
Tract # 241/261452 Lot #
Type of Development Single Family
Comments
Zip 92270 Study Area 123
Square Footage 2794
No. of Units 1
At the present . time, the Desert Sands�s Unified School District does not collect fees on
garages/carports, covered patios/walkways;;.; residential additions under 500 square feet, detached
accessory structures or replacement mobilel times. It has been determined the above-named owner is
exempt from paying school fees at this timedue to the following reason:
r
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.84 X 2,794 c or $5,140.96
the property listed above and that buildinglpermits and/or Certificates of Occupancy for
this square footage in this proposed project may now be issued.
Fees Paid By Laudua Development Telephone 777-1345
Name on the check.;;
By Dr. Carol McGrew
Administrator in Charge
Fee collected /eaeripted by Julie O'Neil x Payment Received
Check No. 831495357
Signature
Collector: Att a,copy of county or city plan check'application form to district copy for al] waivers.
Embossed Orig al- Building(Dept./Applicant Copy _"iApplicant/Re.ceipt Copy - Accounting
�'I
Y