9601-090 (SFD)LICENSED CONTRACTOR DECLARATION `
I hereby affirm 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. 674074 .D :�„^'. V31/95
License # LIC. Class Exp. Date
Date � � , J+/< Signatureof Contractor
/ II
OWNER -BUILDER DECLARATION
I hereby affirm 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).
O 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
1 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 Policy No.
(This sectioppdp q.., Y9 completed if the permit valuatioVJ?DfS9$,,00.00 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 Se'cti6hi 3700.of the Labor
Code, I shall forthwith comply with thos p ows(4lorss'"
Date: A f 2.3 F 9 Applicant 1 L-11 r
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 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 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 repres5ptativees of this City to enter upon the
above-mentioned property for inspectio (purpose
Signature (Owner/Agent)° Date
ALC 'BUILDING
PERMIT
PERMIT
DATE %ill/ fD
VALUATION" aw1.fY.lj��u�r'.�� LOT 1 21-1
TRAC 2 19,:S2 -J
JOB SITE ADDRESS
19-630VLA SAN CLMU'
APN
644 400-022
OWNER
CONTRACTOR
SPARKS CONS" A:Ue.:T ow
T.O. DESEPU EVE'Lt�i�MEW LP '
101. `UA.I�N TON .1�1�ID ONO.
Ro. BOX 17W ; .
" L:;EI. QUWA Cts 422.53
LA QUINTA CA. SY2253
(619V71-:1941. CBI.:#• 2996.
(619)771-194J
DESIGNERIENGINEER
PFKtlRW,-C1ptll+DFAF I,, INC.
? G"I?.1i1Z� .111: .DR,
USE OF PERMITjlN.(;j'.�LE1''ANULYDW LLINC;'
i �•
" A.Vr n OR •f"A :ti )!.'311 7 AIR1
RANCHO LA QUiA9'.l'A
PALACIO PLAN
FEE DESCRIPTION"
FEES
CUSTOM t,c 3T€tCt lcaN,822.000 LF
PORCIf•/.PA;T'IO 180.00 SF
GaARAGEIC,'; RPORN 66&00 5%
• t
FS'a;tME AFM WST OF CONSTRUCTION .
311J.91.40
P.i RMT( FEE SUMMARY
PLAN C`ffEC.KFF,8 iI►1:--(TSOQ-�d39-Z§.f3 �: �1 x3S.�0
CONSTRUCTION' kL6 101-000-418-000 $1,388.50
rc,l.A�a�cAt.r 101000-421.OQO �1a:oel
B .P. n RICAL FE'S 101 000-420-660 V2.V.09
PLUNITMNG FEE 10t-000-419.000
"�'i'C? o A1UTi.t�1� t< -M -11 SiU ;0G 1-000 $31,32
0ADINO i±C9 101-OM'123-{)t}0 924.00
1NtRAS'C.4ttiC11TR, FEE '225-000-443-347 $6,000.00
X'.RECTIS PLAtd 01.0.)0-441-34,5 $25.00 '
A:£X IN>> 80C PLACSS - UIL 701-000-255-000 $M15
SUB- :Ci'C,AL CONSTRUCTION .t AND PLAN CHECK
$%703:16
I.l�$S PRE,- ?AID FEES
4
RECEIPT"�
-DATE
BY
DATE RNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs —
Underground Ducts
Forms & Footings G
Ducts
Slab Grade
Return Air
Steel L
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
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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 yr
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:
v
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 11.1
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE,
Date 2/13/96 APN # 649-400-022
No. 14163 Jurisdiction La Quinta
Owner Name T.D. Desert Development Permit #
No. 79030 Street Via San Clara Lag #
City La Quinta zip 92253 Study Area 123
Tract # 27952-1 Lot # 22 Square Footage 3822
Type of DevelopmentSingle 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 ac,-,essory structures or
replacement mobilehomes. It has been determined the above-named owner is' --xempt 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 3,822 or $ 6,573.84 r
the property listed above and that building permits and/or Certificates of Occapanco for
this square footage in this proposed project may now be issued.
Fees Paid B pment
y T.D. Desert Develo Tele boney'
�? x,771 041
Name on the check }
t'
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $6y573.84
Check No. 7881
SignatureAt LQsn� 0 1 D PLVIA�i'1'l
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
r.
s'of--Occupancy...
•
Certificate of Occu anc -�
Cit .of La Quinta,..'j
Bu.ilding.'a'n'd*.'.Safe.tyDepattme'nt FM of Teti
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,'
certifying that, at' the. time of issuance, this. structure was. in compliance with the various ordinances
of the City regulating building construction or use. For the fol%wing: `
BUILDING ADDRESS: 79-030' VIA SAN CLARA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit- No.: 9601-090
Occupancy Group:, R3 Type of Construction: VN Land) Use Zone: R3
Owner.of Building:. T.D. DESERT DEVELOPMENT Address: SAME
City: LA QUINTA CA
By: KIRK KIRKLAND
Date: 11-6-96