9601-082 (SFD)LICENSED CONTRACTOR DECLARATION I
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, end my
License is in full force and effect. 674074 B 7/
License # / Lic. Class Exp: Date
Date z h,9 ✓. SignatureofContractor
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).
�) I, As owner oT ine property, bm &dIuMVely 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 Policy No.
(This sectiobtbeQdlr1,ctebe completed if the permit valuation -is f6 ,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 compensation provisions of .Section 3700 of ,the Labor
Code, I shall forthwith comply with those,provisi ns 44.
Date: a 1� ? -i Applicant
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 Ilid an7yVeIf li 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 permitto 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 pure es:
Signature (Owner/Agent) i % i! "' I Daie�
ALC
- _ BUILDING PERMIT
PR
PERMIT fl- .2
DATE V I JIM t�
VALUATION 3;
LOT TRACT L f U-
JOB SITE ADDRESS 79-1111 VU, SAN CLAS
APN 649-44&0.14
OWNER
..
CONTRACTOR
Sl1iKIS CONRJC`ION
.
TD. DESERTDEVELOPMENT LP
.
YtL M11awj6E 111) NO,
P.O. BOX 1716.
LA QU19rA CA k2S3
LA QtJ[N'lA CA. 922:53
(61.9)771-1941 C t.0. 2906
(619)771-1941
DESIGNE R/ENGINEE R
ITKAIZ K -CR t1AI )ML, I'MCC.
LISEOFPERMITtI iNt
LAS l' ORESt. C�\. 3t) f71447 ;
R4NCHO LA fati'1MA.
PALAC,10 PLAN 2
FEE DESCRIPTION
FEES
C US'! (YM CO'NS'1'R.UC'I ION 3,1322.00 LF
PORI""ATIO 180:00 Sr.
GARAGFJC'. ARPOWr , 666.00 SF .
x
ESTIMATED COST OF CONSTRUCTION..
° 113, 81.40
i''Ii,RMT FEE SUMMARY
LAN CHECK f fiR 101-000-439-318' $1.,135.?G
C0N'S'1'R1JC'Tlt' N:ME 101-M-418-00) $.1,358.30
IMNAN1'C",AT.:.1 F..1 101-W-421400 $13i.Ut�
L t kii;'11tiG:41, F't 10,1:-000-420-000 $227.09
�t 1J1V1:43tN77 p Lily 1(11. 4i()-41.0-t10L1 s'.Z06.09
;3ralmC3 MO`r'rONvt rism4 - in -,iii) 100-000.243-000 $3132
GRADING FEE 101-006.423-000 S;2U.G(t
1'NFRAM'RUC' VYKr 225-M-443-342 $e,000.00
4'"C_s P! .w 101-000-443-A45
t?�R`.1'.1Pd PLJ;R31C 173: 4;'141 a'? ""I.i 701-000.253-000 553195
i.
.:. {
SUB-MiAL.CC?TvM.UMIGNA9DVLANCUIEG
LESS P.R -PA1U .FBE
S0_0(i
AN 2 2 1996
By
RECEIPT
DATE
i
,
BV' -.
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
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs 1
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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:
,
CGS
V
-Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
-Date 1/22/96 API # +549-400-014
No. 14065 Jurisdiction La Quinta
Owner Name T.D. Development Permit #
No. 79.110 Street Via San Clara Log #
city La Quinta Zip 92253 Study Area 123
Tract # 27952-1 Lot# 14 Square Footage 3822
Type of Development Single F"amily'Residence No. of Units 1
Comments
�ip
}• 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 3,822 or $6,573.84
the property listed above and that building permits and/or Certificates of Occupxicy.for
this square footage in this proposed project may now=be issued.
PT �t.
' .7J.
Fees Paid By T.D. Desert Development LTD 1'Elephoa,e , 77,1-1941=
Name on the check
v
By Dolores A. Ballesteros-
Superintendent t {
Fee collected /exempted by Pauline Pearson Payment Received $6.573.84
Check No. 7663
Signature Y' 1j;:1A10 nn ac
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant CoDv - ADDlicant/Receivt Com - Accounting