9605-104 (AC)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 a ii%ffect•
License # Lic. Class fxp/Date
07
Date �` a *' Signature of Contractor
OWNER -BUILDER D
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 is issued. My workers' compensation insurance carrier & policy no. are:
Carrier <f ATE FU N JJ
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 h person in any mannellso as to beco)Ae sub ect to the
workers' co 'pens tion laws of Calif."rnia, Ad a6ryee 3hat.i I sho d bec me
subject tote wo ers' compensation provisions/of S ctio 3700 of the abor
Code, Ish II f rt witf�rcomply with those pfovis� s. f/
Date: `' 1 � Applicant'' / v r l
Warninb: Failure to secure Workers' Compensation coverage isrunlawful 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 applicator 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 perr'nit to cancellation.
I certify that I have read this applic
correct. I agree to comply with.all
construction, and hereby auihoiiz
the above-mentioned property,.for•i
Signature (Owner/Agent)
and state that the
ipu
of
information is
:o the building
to enter upo
• BUILDING. PERMIT PERM T# C°NTR°`#
960;N-10 3355
DATE VALUATIONLOT TRACT.
SiZt1fS►{I 5iy'��.�.(ett ��
JOB SITE
APN
ADDRESS ilk -0141 Viii SAN CLINRA
'64.9,4,01"24
OWNER
CONTRACTOR /DESIGNER /ENGINEER
DC'sI.{\i' 1i1/G10PfN1NT
.
`(I`RKS /JW'}U 01
1).0, BOX 1716
79295 RAh CHO L A QUiEt!'IA DR.
A (;XAN°fA. t'A 9225'.1
LA 0091"A 91'A. (;A 02253
(61�Y)771-I04t.
(619)711-1941
41
USE OF PERMIT
A1)0ITt(JN
ti
AFX) 1803F, ANO 27f1 S.F. Q C01q ) Pooh
($1,1.00 Vf1lAWOOM
€'t)KCHWA IOC 2.70.60 SI^
EST 1A9ri.i ED COSTOF CONSTRUCTION
PERMIT FES, SUMMARY
€'i: AN t"t-niM FFI! $11 'J•.1 R
C(XN,f5oI'R 1P'71(Y1d FEE tot -000-4.18-000 117.1.00
M1; i::
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs d
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills .
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 17 10�
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
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:
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201 -
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 5/21/96 APN # 649-400-024
No 14494 Jurisdiction La Quinta
Owner Name TD Desert Development Permit #
No. 7-010 Street Via San Clara, Log #
City La Quinta zip 92253 Study Area 123
Tract # 27952-1 Lot # 24 Square Footage 180
Type of Development New Residential Addition No. of Units 1
Comments Addition t0 6Teat Room.
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 aczessory 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:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.84 x 180 or $331.20
'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.
r
Fees Paid By . TD Desert Development ,fir Telephone 7714:4-941
Name on the check
By Dolores A. Ballesteros
Superintendent " C
Fee collected /exempted by Pauline Pearson Payment Received $331.20
Check No. 1562
Signature
Pvv A KI A,, 4 Q' X 1 AIA .fin
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