9605-103 (AR)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 Busjhess and
Professionals Code, and my License is in full force and effect.
License # Lic. Class' E p.12te
l�A !U74 W'; !J!
Date Y Signature of Contractor
OWNER -BUILDER DECLARATION
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:
Carver `.;'l'A'! t .l UND Policy No. la> 1t��ry�r1.
(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 any person in any manner so as to become subject to the
Workers' co'mpen ation laws of California, i/nd a ree t at i¢¢ I should become
subject to f he w rkers' compensation provisions Se tion3700 of the labor
Code, I �foyehil
comply with those p�ovisi ns.
Date: Appllcant . j ✓ q _�
f L...
Warning: Failure to secure Workdrs' 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 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 bui A
construction, and hereby authorize ,reprgg'se �tati esWth ity to enteruon
the above-mentioned property for inspe fio puro osSignature (Owner/Agent) /` . ;/ate
PERMITk CONTROL
* BUILDING PERMIT
So11�_�ithi 3 3 5 4
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DATE VALUATION V7:�zy LOTJOB
SITE
ADDRESS 75-1.10 VIA SAN t'`LAR
APN
OWNERI
CONTRACTOR /tDESIGNER /1ENGINEER
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LAQ1JiNTA (NF1 92253
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POR.0 TUPA'1IO 270.0f) S1r
En 11%-1X ED COST OF CONSTRUCTION
45112 9.60
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CUNSTRIA.""1" ON ITiF 101-000-1118-000 1"1.00
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S53160
1,1 N PRE -PAID F11 S
i) 00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION.
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings - Q -
Ducts
Slab Grade - -
Return Air
Steel
Combustion Air
Roof Deck - O
Exhaust Fans
OX 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 p —
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 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:
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 # 549-400-014
No. 14495 Jurisdiction . La Quinta .
Owner Name TD Desert Development Permit #
No. 79110 Street Via San Clara Log #
City La Quinta zip 92253 Study Area 123
Tract # 27952=1 Lot # 14 Square Footage " 180
Type of Development New Residential Addition No: of Units 1" .
Comments Addition to greatroom.
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
rr 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 Occupwicy for
this square footage in this proposed project may now be issued:
Fees Paid By TD Desert Development, : ; Telephone ��771 l°41
Name on the check
By Dolores A. Ballesteros .
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $331.20
Check No. 1562
Signature pb fano ",ft t A,CL1�!V�_
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.'
Embossed Original- Building Dept.YApplicant Copy - Applicant/Receipt Copy - Accounting