9703-029 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury hat 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
-_
ate Signature of Contractor„ , _i�1- � 11
OWNER -BUILDER DECLARATION V
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).
( ) 1, 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.
( 1 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 Policy No.
IN—`.. CO. .M1': ,2v V.53!)
(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, Is hall forthwith comply . with those ovlslons:_
Date: �" — q 7Applicanf �
I . . t-,
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 inspection purposes.
isignature (Owner/Agent), i�v ' e Date/
PERMIT # CONTROL #
BUILDING PERMIT
9703-Ox9 4 933
DATE VALUATION S131J.4,97 60 LOT 1 % TRACT 261 �3
JOB SITE
ADDRESS 47-0V41) VIA 1AWC A
APN 643460-030
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1,AN0A.0 CiEATI.OPUE-NIT CO3 €IAC'..
MIPRI AL S(<fN C'ON'S"CRJ..tC."[i'iC, M
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PALM SPIVIKOIS VA 92Z76_x
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RECEIPT
DATE
BY.'
DATE FINALED
INSPECTOR
INSPECTION AECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set
Underground. Ducts
,,Forms & Footings
Ducts
Slab Grade
Return Air
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath ofig E-17
Final
Final
POOLS - SPAS
BLOCKWALL APPROV LS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Fans-_
O.K. for Finish Plaster
r La eral
Pool Cover
OmTr Connection
Encapsulation
Gas Pipe
Gas Test s
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)
Building /2_ t? ! n
Address 11 / V
Owner
17�
Zip
malting
Address
City
Contractor
q��
Address
O
City lj /
State Lic.
& Classif.
P.O. BOX 1504 APPLICATION ONLY
1 78-105 CALLE ESTADO
m tin LA QUINTA, CALIFORNIA 92253
zvrr
1 1 ;7-7.7 -i3�/,s
uwsfi:v�-r
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City .3 7 $ ,7
Lic. #f
Designer e�i d [ (✓ /1
Address% 4 / G Tel.
City /� Zilp�i ^, State
�/'�7 -2� s Lic.# C
p S -2 / C/
7
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 Contractors 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 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).
E] 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.)
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 properly 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
. ❑ 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 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: It, 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 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 -Addres
ateMailing-Address
City, State, Zip
BUILDING DIVISION
BUILDING: TYPE CONST.. /• JCC. GRP.
A.P. Number Lo 3 Q
Legal Description ei o+ 7e:? A E IL 2, LPI sa
Project Description./ .�.
Sq. Ft. No. No. Dw.
Size Stories. Units i
New I, Add O Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.1.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation:
.4i
I V23'O3 -3/115.7 .
CONSTRUCTION ESTIMATE
1ST FL. SO. FT. @ $
2ND FL. SO. FT. @
POR. SO. FT. @
GAR. SQ, FT. @
CAR P. SQ. FT. 0
WALL SO. FT. @
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION $
NO, ELECTRICAL FEES
UNITS
MOBILEHOME SVC.
I IPOWEROUTLET
NO. PLUMBING FEES
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
COLL. AREA
FLOOR DRAIN
MECHANICAL FEES
BONDING
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
OTHER APP./EQUIP.
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
GRADING
cu. yd.
$ plus x$
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11/a c
SEWAGE DISPOSAL
FINAL INSP.
SO.FT.GAR @ 3/4c
USE SEWER
PIPING
PERMIT FEE
VENTILATION
PERMIT FEE
HtGAS
RMIT 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./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$ r'C
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
4 . Desert Sands Unified School District
` 82-879 Highway 111
Notice: .
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 5/2/96 APN # 643-160-030
No. 14424 Jurisdiction: La Quints
Owner Name Landau Development Permit #
No. 47090 Street Via Lorca Lag,#
City La Quinta zip 92253 Study Area 123
Tract # Lot # Square Footage 1853
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 nor
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 1,853 or $3,187.16
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. .,Teleuiionet 777 %1345
Name on the check -
.. ti
By Dolores A. Ballesteros
Superintendent'`ti
Fee collected /exempted by Pauline Pearson Payment Received $35187.16
Check No.' 15312
Signature 1 a Qlw. 2 �o 01 A A
Collector: Attach a copy of county or city plan check application form to district copy for all wa2vers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting