9601-091 (SFD)LICENSED CONTRACTOR DECLARATION -
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
C:)C3 M License is In full force and effect.
� C3 U7 ()740 ,4 H it _4:i
r1_ W n License # Lic. Class ExpDate \
rnZ Date vi; Signatureof Contractor
crp p� OWNER -BUILDER DECLARATION
J W I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
U) ( ) I, as owner of the property, or my employees with wages as their sole
Z 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 ext3mpt under Section B&P.C. for this reason
cY) Date Signatureof Owner
LO
N
0 rn WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
Z () I have and will maintain a certificate of consent to self -insure for workers'
L 0 compensation, as provided for by Section 3700 of the Labor Code, for the
X W W performance of the work for which this permit is issued.
0 J -D () I have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
O 0 permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn H Carrier Policy No.
? Z (This section need not be completed if the permit valuation is for $100.00 or less).
00
a O 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 q110visign ..
Date: a ? ' s Applicant _�",
Warning: Failure to secure Workers'Compensafion 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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 wcrk for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information it
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 pu poses /�
Signature (Owner/Agent) �r Z 1)) 1 Date` �' �' �f` /Y
ALC "
BUILDING PERMIT
FERMITX
DATE Ri199di
VALUATION ���� LOT ?
TRACT
JOB SITE ADDRESS
APN
OWNER
CONTRACTOR
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in 0- flOx I e its'
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ioi 40,YI A941 CIV.4- 7141r«
DESIGNER/ENGINEER
004)J'11-1941 11-1941
a:tilor t�3Fk`�eA �,IJ{Y'.
USEOFPERMIT�tiCveiL a tJSslr►r3'•L r 1Vh1
K04,'H i LA t,,AjINTA
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FEE DESCRIPTION
FEES
4 & �;4 P,'vlo'NS`1'H11('TION 3,,Ifjl ld U k,V
mak( 1t41i11XrT0 11500 141,
;AP,AQFX!ARi'ClRT 6118.01 `s1'
M`i IPWAIED COST OF (`0Ni R11!c= 10:%'
nM3f'Y t�wi� IYJtvr}i1��4.�)�ii1,Af';�A`a
lot 000418-00 tt,Z,1.0:
tit! ! °setlJi"11:r�1L t r.!> iGF-Uufi-�u�1 tstt�! �t4:i. ri+
5211.,14
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8,kAU'lk'm i 4&-,-;-ttllti 9G4t 1;3j
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t�at1�1`-42-Ap nx.0%m l0i_fflt1,.V1I 4111
y.d'P IiY 1°TitS1,fL`' 1'2 ii : ° ; 111<`ilI ; '()Z of qty 1111(1 "65 "1
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LESS 113U" Tti' 1T i I`1;'ES
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'996
H
RECEIPT
DATE
BY
DATE RNALED
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 -
Combustion Air
Roof Deck
Exhaust Fans _
0. 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
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:
-
i
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 2/13/96 APN # 649-400-023
No 14164 Jurisdiction La Quinta
Owner Name T.D. Desert Development. Permit #
No. 79020 Street Via San Clara Log #
city La Quinta. zip 92253 Study Area 123
Tract # 27952-1 Lot # 23 Square Footage 3465
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 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:
EXEMPTION- NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Government Code: 53080.
in the amount of 1.72 x 3,465 or $ 5,959.80
the property listed above and that building permits and/or Certificates of Occupaicy for
this square footage in this proposed project may now be issued
` . � s� `_• �J i�
Fees Paid By T.D. Desert Development j Telepho!r1C, 771 1x941
Name on the check d i,
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted,by Pauline Pearson Payment Received $5:959.80
Check No. 7881
Signature r Y�� Qg nn ri V»l 01 A, P, -v\
Collector: Attach a copy of county or city plan check applicationform to district copy for all waivers.
Embossed Original- Building'Dept./Applicant Copy - Applicant/Receipt Copy - Accounting