0102-027 (AR)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 r Exp. Date
r
3117A 'Xwl.MIC fl
Date - f''"°�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, for the
performance of the work for which this permit is issued.
(L#1 I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the wnrk.for which thio
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
lApof
(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 provlsions�
Date%/? t Applicant
:.Warning.. Failure to secure Workers' Compensatiof Coverage is unlawful and
shall subject an employes to criminal penalties and civil ines`up to $100,000, in
"additionto 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. PI
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, & shalllindemnify
& hold harmless the City of La Quinta, its officers 4'ageAts 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 ACity, and State laws relating to the building
construction, and hereby authorise representatives of this City to enter upon
the above-mentioned property/for,inspection purposes.
Signature (Owner/Agent) J Aw ll/,!'�'� 0 Date— ,P a&'
BUILDING PERMIT PERMIT#
DATE"" w VALUATION LOT l�i [-�A'E TRACT
JOB SITE
ADDRESS
APN
_0 n. �.A DY�
7-98511A ,..w.s XU
OWNER �7
CONTRACTOR / DESIGNER / EN INFER
��kk�y AAqqpp�
DON GRAY
7795'5 1c+4-00 LA QUkT,1-+°iDR
82-365 FUGHWAY 313
1A QUIDUA C:A. 9-2253
71iD10 CA 5122:01
X/60)831.6734 G°1JA41
USE OF P((yyE''yyRMIII�T
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5 .I.? RW?d ADDITION
CUSTOM CONSTRUCTION a?
NOWA°13M f OWT OJP colvf2rMUMC9N
�7�YRWi FEE suladtL Zy
lxJ,, N CF's.%` I '1ME 1011000,43p-318 $225,70
C '#I STKL`,t.ki$i'. N IFES 1-01,-000-4ie; 0000 50
MRCTU>;;4!331Crvm, FEE -3 1:01-000-421-000 $40.su
101-010-420.000 �S,slr
PL 0 k1ri<' 101.OW- 1.19.1000 $24.00
IESID
STRONG MOT16N na, '101 -OW -241-000
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RECEIPT
D/A'T,r/) �f /
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 _ _ _
Roof Deck 3 _� a „/
O.K. to Wrap
Combustion Air
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Will Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final �mt 77�1,4
BLOCKWAL• I / APROVALS
Final
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 Piping
Gas Test
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:
l r�
li/
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 2/2/01 APN # 658-270-047
No. 21617 Jurisdiction La Quinta
Owner NameTimothy Flynn Permit # 0102-027
No. 77-985 Street Lago La Quinta Drive Log #
City La Quinta Zip 92253 Study Area
Tract #
Lot #
Square Footage 375
Type of Development Residential Addition No. of Units 1
Comments
Addition is an atrium enclosure.
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code $3080 in the amount of
0.00 X 375 or $ 0.00 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
2•' r
Fees Paid By N/A - Don Gray Telephone
Name on the check ;
w
a j �• e
By Dr. Doris Wilson -
Superintendent
Fee collected /exempted by Annette Barlow
Signature
Exempt
Check No.
$0.00
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) 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 District(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
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