0403-170 (RER)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 Exp. Date
Date Signature of Contractor �' �! r�+ J>r ! ✓�Yr
I- fir. r -...- ...
if
OWNER -BUILDER DECUARATION
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 STATE FUND . Policy No. 046-6579-M-3
Q (This section need not be completed if the permit valuation is for $100.00 or less).
J ( ) 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
3 Code, .,shall forthwith comply with those provisions- a
Date:, � (fgpplicant•.€ r _/`f. :l:�,.ar.iL!��r,,�
i/ 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.
A. 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 upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent•),n / /r f. -t <� ate
BUILDING PERMIT PERMIT#
QS�If-�
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS %sA "T CY.aA£�Ii�+{-��a�i
APN
:u
I OWNER
CONTRACTOR / DESIGNER / ENGINEER
'WI' ILY MEND 'I-
C11AIIM, BM3 ERIS INC
79•d'3`s VIA `:IAN CLAPA
t 45.270 CLUB DRIM
1..�3�I371d`F' CA., 92251
kMJAWW4VU_S CA .92210
(`760)7'12-1011 CHH 4999
USE OF PERMIT
RESL717KNU I,1MOML
1520 S.F. FIRM IatP.i+JI.A,'LZ REBUILD COMPRIS'.3 O ROOF, ilR` VI4IA,
TsL. CT, .iW ti .A.TIGsT7 M1;" ?A.0 &DUCTWORK
MSTOM CC,NSTR13CTIUN 020.00 M
?r "NmAnKIy C01"M 011' CO.IYS`RUCTION
1119,408,00
C:ONSTRUCTICY14,PET, 101.000.418.000 $"io0.4G
PI.PM Ci<'iW"K FEE 101-000439-3 18 $548.94
MECHAl HCAL I7EX 101-000-421-000 s4io0
Mi1'C'1'I;.?:G;AL F110, 101.000-420-000 $&8.:20
PLUMBING FEE 101.000419-CrOlo $63,00
sumn Ia'lr'i.'ncm irn = awsiCa 101-000-ul -000 $11.34
SUB-1'OTAL t;°CJlor'OUR:LTC' 709A'. D PLP C,'I�+ S.w
$1,44 2.88
_ LF -9s PRU-PAFD M, 0
$0.00
MAR 19 2004
CITY OF LA QUiNTA
FINANCE DEPT.
RECEIPT
DATE
BY
DAT INALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —T
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS f
Set Backs '
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
f /
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
fid-
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
y
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
a'
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:
IN
City of La Quinta
Building aC Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
��2�
Project Address: -0 2 j VIA itl t� /��4
Owner's Name: L
A. P. Number.
RL
Leeal Description:
Contractor 61-A'.5 BV/Lt1C'72 � �.
City. ST, Zip:
FTelephone:
X
A
X
8U.t.7- 1199A�
i -a a rort Z flva *5.44 s`;
City of La Quinta
Building aC Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
��2�
Project Address: -0 2 j VIA itl t� /��4
Owner's Name: L
A. P. Number.
Address: --03 Sr V 1 4 5A IV C LARI�-
Leeal Description:
Contractor 61-A'.5 BV/Lt1C'72 � �.
City. ST, Zip:
FTelephone:
Address: — o� ���je�'�^LM D
Projcct Description:
City, ST, Zip: -1-A cl%/l/_%%A— .Z 53
Telephone: 3-�-/��
.� a :_ _ >>::
�00� s -Z
PNCC. 7�SS,,er �� c�r�
State Lic. # : 46 / S� City Lic. #:
Arch., Engr., Designer/
pAl . f�A/ 1-1r /f
c�vn�k
Address:
City, ST, Zip:
Tele hone: '", -.,.• ...' _.;;`;;:":. .=
P;?.... . • �,,,.. :„.:
State Lic. #:
Name of Contact Person: V�� . �/1R S
Construction 3
ction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: 5 Z # Stories: ........#Units:
Telephone # of Contact Person:3-33-,/C/3,5-
stimated Value of Project:
APPLICANT:
DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rev'd
TRACKING
PERMIT FEES
Plan Sets
0�
Plan Check submitted
//�
Item
Amount
Structural Cala.
01
Reviewed, ready for corrections
1
Plan Check Deposit
Truss Cala.
d
Called Contact Person
Plan Cheek Balance •
Energy Cala.
Flood plain plan
Plans picked up
Plans resubmitted
Constrwction
•
Mechanical
Grading plan
Subcontactor List
Grant Deed
Y' Review, ready for correctioissue
Called Contact Person
Plans picked up
Electrical
Plumbing
•
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'^' Review, ready for correctionstissue
Develo jer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P
Pub. Wks. Appr
Date of permit issue
School Fees
Total Ptrmit Fees
i -a a rort Z flva *5.44 s`;
CERTIFICATE'OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road z o
a,�
q Q BERMUDA DUNES h
La Quetta CA 92253 rn RANCHO MIRAGE
Date 3/19/04 f {� INDIAN WELLS
760 771-8515 F LA QUINTAT l'
No. 25715LM DESE
�'
O
Owner Wally Friend APN # 604-400-004
Address 79035 Via San Clara Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # • 0402-170
Tract # Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 79035 Via San Clara 1520 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments Fire Damage Rebuild
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiosAi Nalkways, 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 fol�owing reason:
EXEMPT .
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq. -
in the amount of $0.00 X 1,520 S.F. or $0.00 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 Exempt = David Larson Check No.
Name on the check Telephone 760/333-1935
Funding Exempt
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey 'N Payment steed $0-i 0
Over/Under
Signature r '
NOTICE: Pursuant to Government Code Section 66020(d)(1), this Will serve o ot�Yonstalu 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 b inr ilationpermit 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