9807-183 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date ./r ! lignature 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:
( ) 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, Business & Professionals Code),
( ) I, as owner., of the -property, am exclusively' contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals.
Code). a
O 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,, <
perfor a'nce of the work for which this permit is issued.
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.
VNICARE INNS GO Sy50-1197-14179 .
(This section need not be completed if the permit,v„aluation 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 fortlwith comply with those,pfovisio s?
Date: e'1;7 9 �' Applicant—
/•` •�� ` ,.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties -and civil firies 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'iriformation 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) 1tE Date 17,
}G
,
PERMIT# • CONTROL#
BUILDING PERMIT
DATE VALUATION LOT TRACT / q
h� 271_ A !d
��2`tVS41".3D .
JOB SITE'
ADDRESS {4�'•'�k'i-55} VIA •�i�i,lEiTE ' .
IAPN .1�9J
6'B-.il►Fi
/
OWNER,.
CONTRACTORDESIGNER ENGINEER
iAV%MpsaryMIRAN E .
r
CANADA i & ~OPATI: '
1570:Be;0 .i40i,L'G)W:DfUi ., SiJI' E 708
1��0 �Ri�1�.1;ii3L➢.OW "DRiVE, SME 208
S.ANTA.ANA CA 92705
SAA1'1,A•ANA. CA. 9r_0_51
'(714)751-9.151 CBLff- 4485 .
'. +
i
USE OF PERMIT
Sr%+ ]%LAIN 4M WE£tt4UTDESA NOT INC"'LUDS 13.LOCK WALL OR P00L.
PLAN CHE-0k FEr8.R8D( ED ?3luO>i% SA IE ,
PLAN 7'YPf ,.
l iitll.r i' .,Jtu 7.1 •t'6-V4P�V.t•4 �r.,:'rl'���.t�t7 ov
(7i\ttAii CAf l7RTt' �624XIti tiles
- .i'.+* Y•A Ii.F.FXAf@!+,f)4,.'11 .Y i,�.17'l. .l. .Sft0i l�,•.a'�Olre
.d w�iYy/91ro.rL+ V
TPERMU FEE, SUMMARY
CONSTRUCTION FEX 107-000 415-0(YJ X18.00
PIAN CHECK %FTV 1,01-M-439-319
T8E. D.O."OSIT . 601-•000-439-318 -$259.00
, 301-O ats- i OOG IOS.i►il
� RcHANicAL Pa,
FELEC'TIt[CAI. FFE 107-000-4204M $112.73
PT 4?rWK?vOFE 1!31^00() -41.9 -WO $162,50
S I' ONC11t40'" IOIN rEr-7 - R sSM).101-000-2,,41-000- s t og
GRADMI FEE 101-000-423=000 `. $10.00
1NFRAS17RUC' PURE FFE" 225-W-443-342 '1
ART TN PUBI.W P1~.ACES-.!I'S1.r. 70}-000-�554)M 7. $127.3P.
c
SUB -1"0 T, CONSTRU(:1' ON.r'YN1;,! 01:•FEGK
$4,932„15
.1'LAN
,VS- El'st-PAii? FEES
-$,250,00
.,.. 1!+ "# Ai,1°�",;4%0. 1"s FEES •@�17�+": NO
��,�►�2..3:�
RECEIPT .
DATE
BY,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
y
O -�
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
C�_LT�
$1
Exhaust Fans
O.K. to Wrap
y.5,7
F.A.U. 1110,
Framing
_Za Q&
%7
Compressor
Insulation
_%
Vents '
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
S
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
c
7�7/ L
��
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
(p . .2.7.
T
Encapsulation
Gas Piping
Gas Test
^627
Appliances
Final
Final
Utility Notice (Gas) -- zzyv
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring / G�
Low Voltage Wiring 10
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
- r::4i
Final
utility Notice (Perm)
COMMENTS:
Y?�.v`�rI'.r-v,tiyvr'�ni.�"`+as��-:rrti`+'��^i"F"'''"'°')r�'rw'Y'f%�'til',(lair.r���.'�'•�Y•-...1,4•,,:�•.eyr�... ,.
ceity�, 4 "4
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLS TAMPICO
Building
/ '% � O LA QUINTA, CALIFORNIA 92253
Owner Q
e404c+ Co
Mailing / BUILDING: TYPE CONST. OCC. GRP.
Address ' S 0 � ��
A.P. Number
City Zi Tel. ((,� r,,
'�� 2 (} Ic r�� �� Legal Description HJT' (03
Contractor Cnyn Project Description
a � a 5,5 _1_6 Ste
-
City
City Zip Tel..
State Lic. City
? Classif. 15,91 -SO Lic. q l ' L �` sSq.ize
Ft. SNo.tories
No. s
Arcp, Engr., �l Size Stories Units
Desi g�n'8r Ne Add ❑ Alter ❑ Repair ❑ Demolition ❑
Adijr ;6 Te
1 �"CJd`F� (%I �S 1 l y
City / Zi State
1! ,� Lic. #
d ��CENSED CONTRACTOR'S DECLARATION
I hereby affirm that I ar11 licensed -under grgvisions of Chapter 9 (commencing with Sec ion
7000) of Division -3 df tl1 8u$iness�and Prof ssions Code, and my license is 'n ull force and_,
�(/ % /f l r uV
OWNER -BUILDER DECLARATION 7 /
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 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 or 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 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
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] 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.)
I'] I am exempt under Sec. B. 8 P.C. for this reason
Date Owner
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
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if 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
Ihereby 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 it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
1 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 a0plicant —Date—
Mailing
ateMailing Address
City, State, Zip
PERMIT AMOUNT
Plan Chk. Dep. s so
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
SidiFSetback from Property Line
FINAL DATE 1 INSPECTOR
Issued byJUL L' 3 1000 Date Permit
vy
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 6/28/99
No. 18947
CERTIFICATE OF COMPLIANCE
APN # 643-140-007
Jurisdiction 643-140-004
Owner NameCanaday & Company
No. 78-955 Street Via Triesta
City La Quinta zip 92253
Permit #
Log #
Study Area
Tract # 26152 Lot # 63 Square Footage 2,507
Type of Development Single Family Residence No. of Units 1
Comments
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 l;.i'tti.1i= •
1.93 X 2,507 or $ 4,838.51 the property listed above and"tliat building c.
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be -issued
Fees Paid By cc/CA State Bank/Lake La Quinta Communities �:T.lephon'c `- 77-D9636^!"I
Name on the check "
By Dr. Doris Wilson, ,
t ,
Superintendent
Fee collected /exempted by Juanita Green
Signature
Payment Received $4,838.51
Check No. 51152
NOTICE: Pursuant of Ass>s bly 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 frorj(lhe 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 Dislrict('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
21