0205-260 (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 2�n Exp. Date
661 11021! .ice.'': CS �:.r 1".
5
Date 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 gg&P. for this re onN �� ,Nr
DSte- F»<a� Signature of Owne�� {InA ,.�_.%e'
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 is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 31`ATE FUND Policy No. 10614V-03
(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' compemption provisions 9Q Section 3700'bf the Labor
Code,.Lshall forthwith comply6itR,tiose pro�(Isioris '
,,+••Date:,,,s 0 ,Applicant-r„••�,� `
Warning: Failure to secure WorkersCompensation 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 upo
the above-mentioned;p` perty for Fnspecrtionpurpose�s;
�. i
f f
Signature (Owner/Agent�'�'�� -- `�•�1 '��.`��.•^°'� Date •
BUILDING PERMIT PERMIT��
DATE `VALUATION T27,3;386.50 LOT TRACT
qq_
JOB SITE'Q•%- NA) W3.4 ,f�`A.'Y ENE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
47-2:9p¢:��Sp{iy�IARAAVI;ANA
r" O:�'sOX 1635
[� s{+
CA. 72L.7:b
{y�j...µ
I'1A(,��.f.:id� TA CA 922.13 .
USE OF PERMIT
.r' • I.b.Yd .si �. er,sti,sca'a 0.+1.c7.9 id aex tsy �. e,.vww +.•aw.+tic.. ria.:.s.�n:y r n.++. ary
2PA c» DRIVEWAY APPRk2At111
CUSTOM
PCYR.C�VP ATIG
QATLAWX'tllNi' ORT 30.00
a;•,SUM11711 CO S7 W \i4•id7R`1'.�'fJti."Y#0N
1L'��3CiS�;1,.z�,S>1
a;.t3.t� C;z�l�tr�'r"!:.s+: 1!37-E?f�'L-Vet3if_:3s.f3 '�ii,G93 =•�
V99 DEPOM
Mr.'i:HA.IM&L M, .i -.000.421
CUC'1•I'MAL FEE ?X71 _000.42(_000
Pl UNVINn FEZ i fJ1-000.419-000 33i?�.GO
iT�zt,�'�tl� h')Ca`P t��7 i -T, 21Et '101.0v:J-241000
DVEL'. PER INVAVI PER,
V REC.,Stp, PI.A AN a01 f151i -+1d 1-�A'f )it0.ttd
A'RT fkl P w RUO F°LACT 1- RUM270-000-445-00C IMA7
STYk-T4 JAY. l~ONST:TYC'MN PHD K'I M .N CIM.,X
LY } PIF F-E"Alii:E S
<.t100
1 ; ;� .
MAY 14 ZUU3 '
CITY OF LA QUINTA
FINANCE DEPT.
{
RECEIPT
DATE,
By • /
DATE FINALE
INSPEC
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.
Framing
Insulation
Compressor
Vents
Fireplace P.L.
_ _
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
BLOCKWALL APPROVALS
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
04naHeater
Final
Water PipingPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Z.,
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:
!�
`
.'.�r•....��Y,.r...,..w,rv..p.�r.-„-„�x•...ma'—.),P.,...b.�Mi'1V"•"'-Qvi"h!,
COO
{� ' ilding ) P.O. BOX 1504 APPLICATION ONLY
A �'� ' �f 0 lr I A rti'A c )i)jjA 78-495 CALLE TAMPICO
bu
;/•address L/.t- 6= LA d V I tib'' -,,- .2- • �� . e'_/' - LA OUINTA, CALIFORNIA 92253
Owner _ I
Mailing } / ( * r
Zip ITel.
Contractor n C u 1 0—
Address
ty
State Lic.I City
& Classif. Lic. #
Arch., Engr., 1 I , A t\! k__ A . iVt (f -int. L)
Designer 1 {•11 _ `-1(: 1>) • 1�
Address - f _ /5 IFly_ Tel
City_ • Zip _ State
LA %13L' I iU ' 1,/7
+/ Lic. #
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 Lav for the following
reason: (Sec. 7031.5,8usiness and Professions Code: Any city or countc which requires a
permit to construct, alter• improve, demolish, or repair any structure, prior :!'its Issuance also
requires the applicant for such permit to file a signed statement that he is F_ensed pursuant to _
the provisions of the Contractor's License Law, Chapter 9 (commencing witr Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for thealleged exemption. Any violation of Section 7031.5 by any appJcant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($50.0).
l.: 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. 1044, Buisness and
Professions Code: The Contractor's License Law does not apply to an ownsr 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 wJ have the burden
of proving that he did not build or improve for the purpose of sale.)
17 I, as owner of the property, am exclusively contracting with licensed ontractors 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, anc who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby affirm that I have a certificate of consent to self -insure, +r a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, _abor Code.)
Policy No. Company
r7 Copy is filed with the city. 0 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 dollarr ($100) valuation
or less.)
I certify that in the performance of the work -for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Worker,' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT., If, after making this Certificate of Exemption yor should become
subject to the Workers' Compensation provisions of the Labor Code, yu 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 it 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 rela-Ing to building
construction, and hereby authorize representatives -of this city to ener the above-
mentioned property for inspection purposes.
Signature of a{iplicant Date
Mailing Address
City, State, Zip
WHITE = FINANCE
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description Fly�� I LJ -1
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:
YELLOW = APPLICANT
PINK = BUILDING DIVISION
Sq. Ft. 32I O
Size
No.
Stories
No. Dw.
Units
New)O Add ❑
Alter ❑
Repair ❑
Demolition ❑
6
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
S U -
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
,r
Infrastructure
411 A
I
i
Ju I rl=, k� r,
r
f
r-vv�
r
TOTAL
REMARKS
ITYOF
1NANC
tr -J
.
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:
YELLOW = APPLICANT
PINK = BUILDING DIVISION
I
Date
5/12/03
No.
24416
Owner
Peter Andriet
Address
47-295 Via Ravenna
City
La Quinta Zip 92253
Tract #
Type
Single Family Residence
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
(760) 771-8515
APN #
Jurisdiction
Permit #
Study Area
No. of Units
o
BERMUDA DUNES r
V) RANCHO MIRAGE d
{� INDIAN WELLS
PALM DESERT ,y
LA QUINTA
Q INDIO y�
O
643-100-036
La Quinta
0205-260
1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 47300 Via Ravenna 3210 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14X 3,210 S.F. or $6,869.40 have been paid for 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 CC/Downey Savings - Peter Andriet Check No. 03610098104
Name on the check Telephone 760/564-4883
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey $6,869.40
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting