0304-373 (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 Exp. Date
7776199 B EV50/0-3
Date m; Signature of Contractor`r��� �'^ ✓�? '''�1A
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)• f r 1 - - .
O 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
Sec ion 3700 of the Labor Code, fo'r the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier L173FIRT Y'' MJ1 TUAL F.' Policy No. M
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sh II fo hwith comply wit Mhos@:p�isi ng,s,
J,,Dale: Applicant- _��wf.. C.as'�v►----�". �_
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, indemnity
& 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.
r'
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.
..,o^. Si'g'nature.(Owner/Agent) �'�'f' r � " 'h �y�1""'�'•" Date
rf
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PERMIT #
BUILDING PERMIT
0364.•37,`1
'3�J 3 1
DATE VALUATION9 p ry@f3� LOT . _ sl,;! TRACTJOB
SITE
ADDRESS 8e gs'O.,�., -vS ,, . ER4` S.+Q.
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
7'3,121 F`giI>T/ Ahr°A,"lk .01109-
13^ 121. YRLsC� div"ARM3Y 5) I[XD
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USE OF PERMIT
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LE6 1003A
QUINTA/�E IJEF'T.!
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a
RECEIPT
DATE
'
BY r
DAT FINAL I PECTOR
9�/I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
(11 1
Ducts ,,-
Return Air CrIj
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
/
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
of
Drywall - Int. Lath
Final
Final
—
BLOCKWALL APPROVALS6
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
Water Piping
Heater Final
Plumbing Final
Plumbing.Top Out
Equipment Enclosure
Shower Parts
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final.
Utility Notice (Gas)
ELECTRICAL
Temp. Power Pole
Undeiground Conduit
Rough Wiring
Low Voltage Wiring
Fbduies
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power 44
Final
Utility Notice (Perm)
A PRO A
COMMENTS:
i
s j Coachella Valley Unified School District
]P.O. Box 847, Thermal, CA 92274
(760) 398-5909 — Fax (760) 398-1224
This Box For District Use Only
DEVELOPER FEES PAID
AREA:
AMOUNT .
LEVEL ONE AMOUNT :
LEVEL TWO AMOUNT:
MITIGATION AMOUNT:
COMM/MD. AMOUNT:
DATE:
RECEIPT:
CHECK N:
INITIALS:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date: Janlid>FVY27, 2003
Owner's. Name: Toll Brothers Phone No.
Project Address: 51-829 Via Sorrento 80=4052 Via- Valerosa.50-540 Jefferson La Quinta, CA
Project Description: (2) comfort stations and (1) guard house
772-270-001 772-250-0()� 30357
APN: 772-250-011 Tract #: Lot #'s•
r
Type of Development: Residential
Commercial 1 711 Industrial
Total Square Feet of Building Area: .4142 sq. ft.
Certification of Applicant/Owners: The person.signing certifies that the above information is correct and makes this statement
under penalty of perjury and further represents that he/she is authorized to sign on behalf of the owner/developer.
Dated: 11 Signature:
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project Agreement Existing Not Subject to Fee
17620 65995 Approval Prior to 1/1/87 Requirement
Number of Sq.Ft. . 1142
Amount per Sq.Ft. $ 34
Amount Collected $ 3RR _ 9R
Building Permit Application Completed: Yes/No
By: Carey M. Carlson
Asst. Supt., Business Serv.
Note:
C�
Certificate issued by: ELVi ra Mattson Signature:
Office Technician
NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES AND STATEMENT OF FEES
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written notice to
the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day period to protest the imposition of
these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the Government code and other applicable law, this Notice shall
serve to advise you that the 90 -day protest period in regard to such Fees or the validity thereof, commences with the payment of the fees or performance of
any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether
payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date hereof. This
Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School
District, and up to three (3) such extensions may be granted. At such time as this Certificate expires, if a building permit has not been issued for the project
that is the subject of this Certificate, the owner will be reimbursed all fees that were paid to obtain this Certificate of Compliance.
MV:c/mydocs/devfees/certificate of compliance 09/30/02
'Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 398-59097- Fax (760) 398-1224
Project Name:
This Box For District Use Only
DF.VF.T.nPFR FFFC PATT)
AREA: AMOUNT
LEVEL ONE AMOUNT :
LEVEL TWO AMOUNT: MITIGATION AMOUNT: •
"COMM/MD. AMOUNT:
DATE:
RECEEPT: CHECK #:
RJITIALS:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Owner's Name: o-11 Brothers
Project Address: C5.1-829 Via Sorrento,
Project Description: 2) cOtllfOrt stati-Ons
772-270-001 772-250-0n�
APN: 772-250-011 Tract #:
Type of Development: Residential
Date: JahUd.rvY27, 2003
Phone -No.
ia'Valerosa 50-540.Jefferson La Quinta,
uard'louse
30357 /
Lot #'s:
Commercial Z)«JI Industrial
Total Square Feet of Building Area: -1142 sq.. ft
Certification of Applicant/Owners: The person sign=ng certifies that the above information is correct and makes'this statement
under penalty of perjury and further represents that hef;he is authorized to sign on behalf of the owner/developer.
Dated: -7 , o -� SignaturE :
SCHOOL DISTRICT'S REQUIREMENTS FOR THE OVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project Agreement Existing Not Subject,to Fee.
17620 65995 Approval Prior to 1/1/87 Requirement
Number of Sq.Ft. 1142
Amount per Sq.Ft. $ 34
Amount Collected $ 3RR_9R
Building Permit Application Completed: Yes/No
By: Carey M. Carlson
Asst. Supt., Business Serv.
Certificate issued by: ELVi ra Mattson Signature: &i�
Office Technician
NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES AND STATEMENT OF FEES
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a written notice to
the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day period to protest the imposition of
these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the Government code and other applicable law, this Notice shall
serve to advise you that the 90 -day protest period in regard to suc.a Fees or the validity thereof, commences with the payment of the fees or performance of
any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether
payable at this time or in whole or in part prior to issuance of a Crrtificate of Occupancy. As in the latter, the 90 days starts on the date hereof. This
Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School
District, and up to three (3) such extensions may be granted. At scch time as this Certificate expires, if a building permit has not been issued for the project
that is the subject of this Certificate, the owner will be reimbursed all fees that were paid to obtain this Certificate of Compliance.
MV:c/mydocs/devfees/certificate of compliance 09/30/02