9807-184 (SFD)\.
LICENSED CONTRACTOR DECLARATION
CAI I hereby affirm under penalty of perjury that I am licensed under provisions of
I• - Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
celW Professionals Code, and my License is in full force and effect.
O =) M
License':/ Lic. Class Exp. Date
W_ x59.1561 tj ;� :sr`_+U00
oZ r- DateSignature of Contractor-
0
ontractor O r` ! 1 r
r- U � OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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).
c•`) O I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
ON
Cr)
IL Q WORKER'S COMPENSATION DECLARATION
o IMI hereby affirm under penalty, of perjury one sof the following declarations:
U-) H O () 1 have and will maintain a of
of consent to self insure for workers'
X W compensation, as provided for by Section 3700 "of the Labor Code, for the
m_ Q performance of the work for which this permit is issued.
Q C) L)il'have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'It Z Carrier Policy No.
°�D O UNIC'ARE INNS 00 SC50-4' 197-.14179.
J (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
Code, I shall forthwith comply with those provisions.
Date: Applicant—,_ ✓ _:.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation,
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
`Signature (Owner/Agent) Date
PERMIT # CONTROL #
BUILDING PERMIT
DATE VALUATION LOT1
TRACT Zs 5- 7 4
JOB Sifif
ADDRESS �8*-')3581A ARISSlL
APN
i46 -W5
OWNER •
CONTRACTOR/DESIGNER/ENGINEER
CA�c.POD ..'1Y &10,0MPAINTY
157013KO KEOLLO .DRIVE, SUITE 2(18
1570 8Y:.00KROLLOAV DRJ VE, SUIT rE '20£
SAINTA ANA CA. 92705
8AI+1"rA, ANA. C:A
�ry9270.5
(714)751-9151 OBI. }`P 4185
USE OF PERMIT
SINGLE FANLY D•Gd-i:1.UNC,
S.M. - PLANJ 4.AR - PMUT i' OE$ WOT INC UM, BLOCK WA, LL,. .OR POOL
't"}'ACT CONI STRUCTLON 2507.00 Si:
PORCI;UP'ATIO 189.04 Sr
CI.A.R.AOFdCARPORT 62:00 SF
a
NSTM:ATED CM OF COINSTRILIMON
150,87;113
PERMIT FEE, E, SUN�"s'�t• RY
C0N'SiRUC 11(Y f IFEE 101-M-418-000
P1,;AN C EW -C.. F►7 : 101}./O'�(U�(f�)-4Z���-+.��.ii.?b3
�Siy�9i/./9�1
S LX, DC:a[ OS11, .101.-000-4 9-318 _51250.00
.
3 riCUANICAL FI 101-000-42,i-000 $105.00
O.ECIR1'CAL r -h- 101-000420-0W
PIAIN AYNO'1 ER IM -00-41.9-000
£'"1 H2O iG iti. D`.F'xra3la :r L� -REED 101 -WO -241:-v00
i",il✓lr.)IN(If FEE 101-000-423--•000 $20.00
I-NFJtA3TRUCrUR8 FEE - 225-000-443-342
• A,RT 1N 1'}'l3?: K; P? ,A � - U",14r. 701-(1f1f1-255-000
SU.O-TOTAL C ON'SKrA ,IMON SAND PLAN CHECK
&%453.54
LESS •1 ICE-PA'i1. FEES
..$260.00
T0TAL'§'ER11%!997 ;ii'E1i!`-S1)tTf, le'ONV
Sti�,�03
RECEIPT
DATE
BY "''
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts -
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
--/ l
Exhaust Fans
O.K. to Wrap
o —( Z_ —
F.A.U.
Framing
10 — — Qr+ j
Compressor
Insulation
t 5r
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/l -Lz
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
f/
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- Q F
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final.G--
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:
.... � _ T r ,1+rX s. �,�i�.. �,.� s. .,,�� .. -... ,.• s-rn--vim• �f ^rr ..�. y_.+,,, �.. vr-... .:.ti'� ., ;r-�a'n n� -.. -
��, i*
BOX 1504 APPLICATION ONLY
Building �j'2 1 78-495 CALLE TAMPICO
Address 1 > �'� } r'' LA QUINTA, CALIFORNIA 92253
Owner
Mailing
GO. BUILDING: TYPE'CONST. OCC. GRP.
Address I;? 0 C&0)d no l 1}
6 0
A.P. Number
("C- it Tel. p-
`� Aim �� Legal Description
Contractor
Project Description
q93 i a�it�s
Address
City Zip Tel.
State Lic. City
& Classif.S� ��, Lic. # L. Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
Dd-S1 r r5 L En oe' New Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
90 &-- Q(1 _r,Li,, srM30
City' T)� Zip �3 State
V Lic. #
LICPSE fCONTRACTOR'S DECLARATION
I hereby affirm thatf, am.licensed wader provisions of Chapter 9 (commencing Ith SectioVFJ Vv,
7000) of Division 31of the'Busi ass n" Profs `si'bCs Code, and my license,;isss777in yl IT%y/
d
effect. d' %
SIGNATURE,
DATEI
OWNER-BUILDER DECLARATION Estimated Valuation
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, atter, improve, demolish, or repair any structure, prior to'Its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to PERMIT AMOUNT
the provisions or 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 _ 7 �U V o
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit Plan Chk. Dep. v
subjects the applicant to a civil penalty of not more than five hundred dollars ($500). Plan Chk. Bal.
I-! 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, Buisness and Const.
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, Mech.
provided that such improvements are not intended or offered for sale. It, however, the building
or improvement is sold within one year of completion, the owner-builder will have the burden Electrical
of proving that he did not build or improve for the purpose or sale.)
I'1 I, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing
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 S.M.1.
such projects with a contractors) licensed pursuant to Me Contractor's License Law.)
Grading
1-1 I am exempt under Sec. B. 8 P.C. for this reason
Driveway Enc.
Date -Owner- Infrastructure
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
f] Copy is filed with the city. O Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS '
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation -f
Of 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., 11, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) 1'h .•- Si;e*,, etback from Property Line
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE INSPECTOR� ��
expiration if work thereunder is suspended for 180 days. (90
I certify that I have read this application and state that the above information is correct. Issued by. I>>` I� Date Permit
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. Validetedaby:
Signature of applicant Date '' G e
Mailing Address Validation:
City, State, Zip
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
0
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 6/28/99
No. 18945
Owner NameCanaday & Company
APN # 643-140-005
Jurisdiction 643-140-004
No. 78-935 Street Via Triesta
City La Quinta zip 92253
Tract # 26152 Lot # 61
Type of Development Single Family Residence
Comments
Permit #
Log # '
Study Area
Square Footage 2,507
No. of Units 1
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 ` I'll tl a a,'r(caunt of
1.93 X 2,507 or $ 4,838.51 the property listed above a"nd that'building x;
permits and/or Certificates of Occupancy for this square footage in this proposed project may nZw b6iissued r.; �
/ '•-. •, '1"F ' is �..r.
Fees Paid By cc/CA State Bank/Lake La Quinta Communities Telb hone- 771 •9636`.;
Name on the check t¢ v
By Dr. Doris Wilson t '
Superintendent
Fee collected /exempted by . Juanita Green
Signature
Payment Received $4,838.51
Check No. 51152
NOTICE: Pursuant of AsseLtbly 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 ident�ed
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
collect them on the Districl('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/Receipt Copy - Accounting