9605-102 (AC)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 of1the Business and
Professionals Code, and my License is in full force and effect. 1
License # Lic. Class xp. ate f
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117• )J f /;t il;
ri
Date S 7 /Signature of Contractor— ! / 1 s
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 uwnar of tree property, 9M ueluSlvaly 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 iT:1.f' r�Policy No. %31UfiNa
(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 torbecame subject to the
workers' corn ensation laws of California,, d agree�th#if I should become
subject to th worf1�ers' compensation prov),!slon lof Section 37 0 of th Labor
Code, I sha ort (yit comply with those pfovis (ns.
Date: 5 �1% Applicant ,�� L `--
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 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 thaYhe above information is
correct. I agree to comply with all Cityt and Strate laws rela 'ng to the building
construction, and hereby authori e r�pre a f,atives/,of thi City to ent °r upo
the above-mentioned property{foff In E on purposes.
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Signature (Owner/Agent) ' t �t V/ f Date ' - I
BUILDING PERMIT FERMT# °°NTR°`#
$ 3353
DATE VALUATION LOT TRACT
IS40196 SJ5119400 i'3 179524
JOB SITEA
APN
ADDRESS 79..1,��'i �'JA N.Ai1! '�.�li.tf��' A
649-404i-i"D13
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r i ) I )rsritt, r I. It-i,vr1.61ttN!_! -PT r
S P A R 1K.S ("Al S!, r 11{ "f'{ON
;.u. 800 17Io
79295 iU\Nt'HO LAQIJ1N A DFL.
LA Q1.I01M CA 92143
LA C?UfNTA LA 02253
t61141771-10411
(713 ,,1' 2906
USE OF PERMIT
AL?ll1'4'Jt ajv
fit 0 1St► °i,la TO CIRYL,i\"I' f2(X)tvf ($11.1628.00 VA IIATION) AN) 1(t S.fr 0F" C0VLHf D P0RC.1.1
r�;'�,C9) tN3'Ir�{riFA'i'ic7N1
IAC}R I1PATIK 2'70.00 Sr,
ESMIIKATED COST OF Q:' NSTRTiCS.10N
151219.0
P,PRMIT rVTS'lf111A9ARV
PT.A:Nt"`31f+t"KV&&H . 101-0(X;-X13?-�1.R $1.!I.1t
1"tC�f�31131" 10114000-40340 V7.1.00
MT+,c;.11ANI AL F Mi.i l-4G�- t-C,Ck1 545.C�ii
1:L,LX`1'121rVA1. FRE $21110
1`14F'R11S1 Rfit"'t'1)R 2 FIT
STONG MOT 10114 1:`; i - iZB.W 101-000-241 ^W, S 1.52
SCJiZ-TOTAL UOEiSMIi1.P4MICIN AlY}}(.1{{++.CP��.Att AN C.vJ''[[r.��EICyK
'S5S1
`
FE
/V�v
TO'!.'.AII, PVRMI'f F ir..> S DUE NOW
$581.60
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
P
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 Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
�—
Drywall - Int. Lath
Final
Final r► .e s s
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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 Laterat
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
I
Desert Sands Unified School District
82-879 Highway 111 y
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
t
Date 5/21/96 - ,` APN # 649400-013'
No. 14.496 Jurisdiction La Quinta.
Owner Name TD Desert Development Permit #
No. 79120 Street Via San Clara • Log #
City La Quinta zip 92253 Study Area 123 ,
Tract # 27952-1 Lot # 13 t Square Footage
Type of Development New Residential Addition No. of Units 1
Comments
At the present time, the Desert Sands Unified School District does not collect feeE 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
X schobl fees at this time due to the following reason:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
r 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 Occupancy for
this square footage in4his proposed project may now be issued. ,
Fees Paid By TD Desert Development Telephone 771-'1941 .
Name on the check
By Dolores A. Ballesteros 7 ,
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received,
_ Check No. 1562
Signature �fli_ A t w �K w X.
Collector: Attach a copy of county or city plan check application form to district copy for all wa�,vers. `
Embossed Original- Building Dept. /Applicant Copy - Applicant/Receipt Copy - Accounting ,