0005-298 (SFD)LICENSED CONTRACTOR DECLARATION
q� I hereby affirm ti der penaltytof�perjury that I am licensed under provisions of
ter,9 (commencing with Section 7000) of Division 3 of the Business and
signals Code, and my License is in full force and effect:
License.# - t Lic. Class Exp. Date
7111
%Date , 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),
( ) 'l, asebwner of the property, am,exclusively contracting -with licensed
'contractors,to construct the project (Sec. 7044, Business& -.;Professionals
Code).
O I am exempt under Section B&P.C. for this reason 4
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following, declarations: N
() .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 foF which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
-Carrier Policy No. .
i?�a9MONT COMP 11,19 SE3D-k 19�A0-141'I9
.(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
J
workers' compensation -laws of California,' and agree that if I should become
subject to th p�'orkers' compensation provisions-of'"6 ction 3700 of the Labor
Code, I s6 ff¢rthwith comply with those provisions,,
Date: J (�'.• 33 , 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
0'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 or, Insaection purposes.
to
Signature (Owner/Agent)1 Date
PERMIT PERMIT#.
fff-BUILDING
DATE /�/ J� VALUATION LOT, 9`298 TRACT -.
$14S,146,40
/ t 61x2
JOB SITE
ADDRESS 47-815 V1, � CH_
APN'
Z.
� �- �/
OWNER
CONTRACTOR /DESIGNER / EN INFER ..
ADAC' COWA1,TY
CANAifi Y & COMM*
17480.F. 117H S1: #106
114801`•, 1:7T -T lei. #106
77b iN dA 92780
1rumm CA .92190
(714)508-4440 C01Jt 44"
USE OF PERMIT
•G FAMU Y DMLUNa
„r
VD, LOT &1 PLAN l0AR-PER.i1911' DOn NOT IWGLUIJfi BLOCK WALLS OR,, ,
POOL 750A iE~1M CHECK PPF. REDUCTION FOR MUL�l'1M1S3AVIC ; OF
SAPtdLt' PIAN TYNE.
TRACT CONSTRUCTION SF
�?,4�27,00
POR.CI IPATit7 .i1{i 51r
CIARAOEICARPORT (S -F) �644AD
M—�1�' ATM CO S7 OI, COT RU's ION
7 4�,1 �°G.�O,
pwr YCE sruhaAHy
CONSTRUCTION "31 10100.418-000 $860154
PLAN CHECK FEE $165,99
TOSIT . '' 1011!000-43!�-31€1 4250100.
ti
iVIECtMNICALFEE 101-000-421-600 $98:50
ELP,CTRIC.AL FEE' .101.000.420n000 81410
7
PLUXasilar . 1; 101 �000-43 9-fl0USI�sm
i, }
STRONC9 Mc7T1014 rW -.RESID 101.000.241-000. 5101.
b ,�
GRADING NE;� 141-f 00-4,"3-000
Dt:'�IEIAPE1t $,MPACT h E $loS�tY7r00
�,; I
r F
t3B-1'CST.AL M 7-RUC11014 AND PTA1;! CITY.
274.29
LMS Prm, PA1Q1~'Eym
4250.00
TMAL nwnr nms D' VEP w
.29
RECEIPTD
T
BY, y w.-•.�
D F
INSPECTOR
fg�
INSPECTION RECORD
OPERATION
7 BUILDING
DATE INSPECTOR
APPROVALS
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Set Backs
',
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—
Return Air
Steel
Combustion Air
Roof Deck
- 25'!s0
Exhaust Fans
O.K. 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
Z/16
Drywall - Int. Lath
ZH
Final
Final
POOL
A
- -PAS
�f
BLOCKWA
A PROVALS
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
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:
��e.@s o•C G e� 8 � i—�
Final Loa
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring or
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) L
-.. ._.-r -.-�.. .,.1.,. ..r..,. .-: _.. , ..w - .�.�,.--e4,ri�>'r-a.�+.,ec74r�rra'p"�'4."+yI`ry"�+°4` .. �*'�..!n�'icsiJ'•?-,--.,-....-n-u'7--y....r-.-t. _. --v -
•
P.O. BOX 1504 ' -
APPLICATION ONLY
Building t •� C� 78-495 CALLE TAMPICO
Address q7 t�.,` i S 4i� r! t(! LA QUINTA, CALIFORNIA 92253
Owner � I
L (Jclz r o �" U � � (brA BUILDING: TYPE -CONST. OCC. GRP.
Mailing
Address 0 Y
l 1 �1 - 9 ^ Q , QQ A.P. Number -
City t Zips. �Tel. Legal Description
Contra ctorProject Description i -3
.
n l4 coi
Address
i t
r"
City Zip Tel:. �'
State Lic. f ( City.-. , ,_ r ` j ��'
& Classif. A g U 12 Lic. # �� Sq. Ft. No. No. Dw.
C.�
Arch., Engr,, ( Y Size Stories Units? 1
Designer \ 67 b �' Ne Add ❑ Alter ❑ Repair ❑ C,;, Demolition ❑
� � �.;
Address (11r)r) ��) `Y , �i�ti?UtC7 � ( 9 q� 5 yh` .
City` ' ` Zip Lic.Stat#$
YV vv LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I 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.
i
SIGNATURE DATE
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, 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 PERMIT f • AMOUNT
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 Plan Chk. Dep. O./ � �(,/ � - ASO
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I- I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Bulsness and Const.
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, Mech.
provided that such improvements are not intended or offered for sale. It, however, the building
orimprovement 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 of sale.)
I.1 I, as owner of the property, am exclusively contracting with licensed contractors to con. Plumbing
strucI 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 the Contractor's License Law.) -
Gradirig
i] 1 am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date owner Infrastructure
rsw
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. ' 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
Of 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.
Date Owner
NOTICE TO APPLICANT: If, 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
1hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
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. Issued by: 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- ! a�.t
mentioned property for inspection purposes. }Validated by:
Signature of afiplicant Date
Mailing Address Validation:
City, State, Zip
` WHITE = FINANCE YELLOW = APPLICANT PINK .= BUILDING DIVISION
Desert Sands Unified School District •
47=950 Dune. Palms Road `
-Notice: La Quinta, CA 92253-'.,
Document Cannot BeDuplicated f � 760-771-8515.
�' . "�:. `••CERTIFICATE"OF COMPLIANCE. ".•� r • - ''`'�
Date, 5/31 /006437140-028_
al'ly #
No. "20496 Jurisdiction1 La Quinta
...
Owner NameCanaday &' Company,.
., : �.} Permit #0005-298 f
No. 47-815 Street Via Zurich ` Log # +
City La Quinta zip' ',92253 a1 Study Aiea '
Tract# 26152 Lot # 84
7, Square Footage { 2422'
1.
Type of Development Single Family Residence J. � � ', -7 No. of Units: 1
Comments
r
'A a.
At the present time, me Vesen Sanas ,unmeo z5cnoot .vfstnct noes, not couect ices on garages/carports, coverea
patios/walkways, residential additions under 500 square feet; detached accessory. structures or replacement mobilehomes. It
has been determined theabove-named owner is exempt from paying school fees at this time due to the following reason:
— A
_ EXEMPTION N.OT,APPLICABLE
This certifies that school- facility fees imposed pursuant to Government Code 53080 ,in the amount of ,
2.05 X -2,422 or $ 4,965.10 ,' the property listed above and that building, • '
permits and/or Certificates of Occupancy for this square footage in this proposed project may nova be. issued _
Fees Paid By CG/Bank of America/Sue Pelletier "j ' ' ` �`j =F "
,. ; Telephone760-771-9636;
Name on the check r e
By Di: Doris Wilson^
Suillerintendent
Fee collected /exempted by' Mary Ann L. Borja VPaymentReceived. 965.10
t
Clieck-No: 2004888073
AASignature
R ,
NOTICE' Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9G -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 t
collect them on the District('s)(s')'behatf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers. , `;
M Embossed Original- Building Dept./Applicant Copy I Applicant/ReceiptCopy Accounting-- _ '