9609-182 (SFD)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
CV W Professionals Code, and my License is in full force and effect.
7) M License # tic. Class Exp. Date9t,
CC
ZLLJ r /Date r°' ISignature of Contractor -
a,Or�_J 0
C° ~ OWNER -BUILDER DECLARATION
Ha CD I hereby affirm under penalty of perjury that I arr exempt from the Contractor's
C0 License Law for the following reason:
Z_ ( ) 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
LO
N Date Signature of Owner
ON
C7
Q WORKER'S COMPENSATION DECLARATION
p CC I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
QU 1 have and will maintain workers' compensation insurance, as required by
U
O Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
"t Z Carrier Policy No.
oo 5 ; r1Tl ii�JIND 41,81,I0146r
CJ
Q (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' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
bde, I shall forthwith comply with those provisions: `
✓✓✓✓✓Date:, ` Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
q, application. o.
1. Each person upon whose behalf this application is made& each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such'
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct..1 agree to comply with all City, and State laws relating to the building
cons ruction, and hereby authorize, representatives of this City to enter upon
/thgabove-mentioned propertyfornsp��tion purposes,sature (Owner/Agent) Date'
BUILDING
(G1 PERMIT
PERMIT#
CONTROL#
U 1R
��I�.s��
4719
DATE `2111f)(97 VALUATION ' S391,273 M LOT
TRACT
JOB SITE
ADDRESS 4",N) VIA.Slti RR,%.
,d
APN G.31-�.It)>Ol9
OWNER
CONTRACTOR/DESIGNER/ENGINEER
: fT.T,1A11rT IT Il,i1[,Tii l7f T31f3
S"T"ARK t o" . TV`k2.(.li'`')'ION
C:if.):
48690 VIA Sre..KkA
39723 GMAND tiF`
LA (XIINTA, VA 9225-1
1'AL&I CJIs�"Wr CA
9Z71 1
(614045.9711
CUM V0
USE OF PERMIT
tier
!'!-PLI'Mlt C aiv+OXI[OhS f:4ilt0EN WALLS r 144 kN"!R ,'t1 ! SROWN ON Sl"f..'ts
III. AN.
i'i; j!${aYls['A'.l.1CJ 18U.001
:it'
c.iAXA4*r CA. lt�'C R.T 837,06
SH
I VT_ WALL
91) 60 11V
4€"1' WA T< 7A8J)0'L
ES'1'%1%CV18) C,'C;ff 6'J1+ 10OM'i`g'>ktllCIION
391,273.30
r"ONS'I't(>:I(TIoN VFJ3 O.Ut -t)i 041,8-000
141: AN r i+1s(`, VI°.r ilii (3t)�1-i3�,>-31i1
�1,3iit�
VEX IM -'POSIT
rVILA11>9 NIC;AL Wikvi.i11 (Kk➢-121;
15G.tki
J!i.►1.C`1`JtKW. T f•E 101-(1i'10-4241-( 10
S27898
N.fROM NO'11 F 1fIi.O(Ni-41.`► 0th)
";'?11 t)(1
S'.VO 6Nfti1'ft,JNFEE,-RES11:1 1.01-000-24.1-000
VAY,13
t 9kJi!>NO VM3 1 A -1300-4'23-(W
.$20.00
1NF'.RA.S`rkt KTIJl3F'FCSS 2"00-443-342
PRFOi` F f't;;.+>EN a~ 10I r013f1•. 41_Z43
.{;112 f IN "WRIC PLA "IiS - ?(t1 s31: 701 -Wo 255.000
84)R'fUi',Af,C`'(:iN�,S.''-_ktJ&PON AND 11,ArtCHI�V.
510,476,76
P" 8'D
TOTAI.r PERM T L''EE. NON
.J9,476.76
FEB 1 9 1997
RECEIPT EQ 11y o
BY'
DATE FINALED.
INSPECTOR
r '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 1A
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
POOLS - SPAS
BLOCKWALL APPROVALS
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
Water Piping
Heater Final
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
TAty 14
P.O. BOX 1504.
Building7&105 CALLE ESTADO
Addres/ G ., G �� '� J—iG� �' LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address CLZ -a
City Zip Tel.
111f16 z " 07
GG
Contractees
City
'-1
State Lic. city
& Classif. Lic. #
Arch., Engr.,
Designer �C�G-�SSoc' Tr✓ES
Address Tel.
73- ZZ i y . %i% �G%y) 773- 6GG-
City / Zip State
60 Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I -J 1, 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
1'1 I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 I am exempt under Sec. B. & P.C. for this reason
Date Owner
r"
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING DIVISION
APPLICATION ONLY
BUILDING: TYPE CONST. OCC. GRP.el
.
A.P. Number ! c-_
Legal Description
Project Description
ZONE: BY: - �-
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
GCi4fi
Sq. Ft. r
Size ,j,S
No. No. Dw.
Stories Units
New Add ❑
Alter ❑ Repair ❑
Demolition ❑
/Inv �
Q
�l%t/�/►�� ,
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
,
Infrastructure
(n
Xj
1\
TOTAL
REMARKS
t
I
`
ZONE: BY: - �-
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO, ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. g $
2ND FL. SQ. FT, tz
POR. SQ. FT. Q
GAR. SQ, FT. @
CAR P. I SO, FT.
WALL SO. FT.
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM J�
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. @ c
BATH TUB
SQ, FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 114 c
SEWAGE DISPOSAL
SQ.FT.GAR @r 3/ac
HOUSE SEWER
REMARKS:
VENTILATION
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
= ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP..
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
.7,7 .r Y. .. ..
N
Notice:
Document Cannot Be Duplicated
Date 2/13/97
No. 15262
Desert Sands ;Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
_.......-. Jurisdiction
Owner NameMr. & Mrs. William Dodd
�
No. Street
48- + 0 Via Sierra
City La Quinta zip �: 92253
APN # 631-810-019
La Quinta
Permit #
Log #
Study Area 109
.Tract # Lot # Square Footage 4664
Type of Development Single Family Residence ` z y'
Comments
No. of Units 1
At the present time, the Desert Sands Unified • School• District dohs "hot 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 pursaani'to Government Code 53080 in the amount of
1.84 X 4,664 or $ 8,581.76 ~, S the
.._p perty 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 Certified Check/Merrill Lynch{,+'.Pierce,Fenner. & `
Telephone,. 34- -9
5, J741 Y �
Name on the check'M., Fye r
B Dr. Carol McGrew
Y
Administrator in Charge ... -+' `. A
r V
Fee collected /exempted by Ellen Patino ~ - Payriieht"Received 76; is
, Check No. 5469
Signature
140TICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you 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 building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
:ollect them on the District('s)(s') behalf, whichever is earlier.
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/kecd ! ipt Copy - Accounting