0005-302 (SFD).. .. a .. .. .. , . -.; •
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Owapter 9 (commencing with Section 7000) of Division 3 of the Business and
`^ Professionals Code, and my License is in full force and effect. .
se # Lic. Class Exp. Date
3 5 ! k3 09A JZt
Date" Signature of Contractor !
OWNER -BUILDER DECLARATION
I hereby affirm under,penalty of perjury that I am exempt from the Contractor's
License Law forthe 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 owner, -of the- property, am exclusively contract g -with -licensed
contractors to/construct the project (Sec. 7044, Business &, Professionals
Code). r '
{) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
t
WORKER'S COMPENSATION DECLARATION
I hereby affirm 'under, penalty of perjury one of the following declarations.
'( ) .I have and will maintain a ceirtificate-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.
O 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
perrnitt:is issued..My, workers'` compensation insurance carrier & policy no. are:
Carnegy
,'FMMONT COMP TF33. Policy No. :0ES0-11.9900-!4119
t( -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'elTmploy 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 prrosions o Section 3700 of the 'Labor
Code, I s. a �f�rth. ith comply with those provlslon
Date: / 1 '7 Applicant E- '
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, indemnity
& 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 voidif,
work is not commenced within 180 days from date of issuance of such
t permit, or cessation of work for 180 days will subject permit to cancellation. .
I certify that l 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 propertyfor inspection purposes.
Signature (Owner/Agent) Date/
BUILDING PERMIT PERMIT#
s
001AS-302
DATE f! VALUATION LOT _ TRACT'
261116,
JOB SITE
ADDRESS �i
APN
t_ 'N
OWNER
CONTRACTOR / DESIGNER / EN INEER
C MA AY &" !OIvS Wy
CAWADAY &C OMPA.te F
'1 7400.E, 17TH U, it'! 06
17480 IL 17TH ff, #106
�
_Idmw CA W180
MW
CA
92760
('714)50£4440
,•CML 4465.
USE OF PERMIT
.yFD. LOT R8 PLAN 3OBiIyEAMIT.DOFS,NOI' ti1G;.1,,UD.9 BLOCK WAI,)4 OR
•`POOL,, 75% PLAN CHEXt FEE REDUCTION POR MUTAPIPLE IMSANCF, O
BA.ME PLAN TYPE.
• "` '
..
TRACT C
ACT CONS 3UCTtOT,
,
PORCHIPA 10 �, 715.00 SF
A€1X#tCA.RPOR (OF) 1 :Id.Od
EYM. I i.' COST 010 CONSM.UC71011
� 4,
100 751.70
:
CONSTRUCTION FU .101.000416.000 $92)100
PLAN CHECK 11% $194.04
~^�
FEE DOOSIT. - 4254.00,
MFF., HANICA1.. FE `. 101-000-421-000 $105.60
i�-
E:GECTIZ.iC,AT, k'�`I, !til •00(1•�P�O�a�?(P old%29
�,�;�
' =��a
PLUMBING FEE ' 101-000-419-000
STRONG MOTION Fft -,WID 101-0QQ-241.000
ctRAWTO ft�101-000-423- iNI,
]DEVELOPER IMPACT FEE �I,S►07.fgp
SUB_ 0Tn CONS`xRUC170%9 Atm P1: W t' 1WK
$3,526.911
IMS PSE -PMD WS •
•$250.00
v
RECEIPT
DATE ,/ 'qq
BY/N _ - ^
D INA D
INSPECTOR
.
INSPECTION RECORD
T' `"VOPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Root Deck®�
Exhaust Fans
0. K. to Wrap
6—zz_
F.A.U.
Framing
— =61
Compressor
Insulation
o ^ p .l 6'
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
i
Final
Final
BLOCKWAIZAL
/
APPROVALS
Steel
POOL - - PAS
Set Backs
Electric Bond
Footings
Main Drain
—
Bond Beam
Approval to Cover
y '
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
— Ga
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
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:
ry--.,.,.�,.-•'Y^(:v'^7,irii77*.:';w„r"7(�' Kw:YQ:;1�i �'v'"ia'�{ l:.":L.'. �='?��x� 1; �:�'
A'hf
44-Q"
P.O. BOX 1504
78-495 CALLE TAMPICO
�C \^ LA QUINTA, CALIFORNIA 92253
,t
Building�5 \ ! n
Address "� ��
Ownet'/N I A ...
Mailing '
Address 1,7q5
L
city"__
Contractor /
Address
l -A `r
APPLICATION ONLY
N. \,I W, "� y BUILDING: TYPE'CONST. OCC. GRP.
r ^,
/ A P Number
Zip T?
/
City JZip
Tel. ,
�f y�['
Xq �1 40 Legal Description ` � �J _ " �' -
r� Project Description
W
,E r i
T ie �.
State Lic.-+ City
& Classif. s Lic. A-1 q
Arch., Engr., r a
Designer,{
Address
Cl Q,
j
City " ZlpSta
�C L.� Lio-tr# '1
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.
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,Susiness and Professions Code: Any city or county which requires a
permit -'to construct, after, 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 3of 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 penally of not more than five hundred dollars (8500).
l 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.)
H I, astowner 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.)
1-1 1 am exempt under Sec. B. & P.C. for this reason
Date owner a
i
'.
WORKERS' COMPENSATION DECLARATION
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.
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.
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 a0plicant Date
Mailing Address
City, Stave, Zip
Sq. Ft, No. I No. ll
Size / Stories /J Units
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
4 I A
I
Estimated Valuation
PERMIT Uy AMOUNT
Plan Chk. Dep. 6 Q Q
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
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
13
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands, Unified `SchoolVDistrict ,
47-950 Dune Palms Road,
Road y
}
-Notice: LaQuinta CA92253` "
T '
Document Cannot Be Duplicated " 760-771-8515 „ t
y t.• r.` a
„CERTIFICATE"OF COMPLIANCE.
Date 5/31/00APN
APN #
No. 20500 ' `" • `.,, Jurisdiction La Quinta r
� s.& Com ari �.
Owner Name Canada y p . y ° Permit. # 0005-302
No. `47-935 Street � Via.LZurich '• t - Log # ... .-a .
City.La Quinta }', _ - zip '92253 Study Area
`3034, ,
Tract # 26152 Lot #` 88 Square Footage '
d
' Type o_f Development Single Family Residence _ No. of Units 1
Comments'
u 1�
t
"At the pr
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: ,
+ #r 44
' EXEMPTION NOT APPLICA_ BLE
This certifies that school facility fees imposed ptusuant to ` Government Code 53080 i4 the amount'4 +
_.
r' 2.05 X' 3,034 ` : or $; 6,219.70. t r the property 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 CC/Bank of America/Sue Pelletier t r" '
Telephone ' 760:.771-9636
Name on the check' ,s4 #v .�, • t • 'S
By ,Dr. Doris Wilson,
-Superintendent ;:.77
, ,a
Fee collected "/exempted by' Mary Ann L. BorJa Payment Received ` �. $6,219.70s(; :7= -
` , +' Check No. .20048880730
Signature
�'•
r• NOTICE: Pursuant of Assembl ill 3081'(CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval eriod 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
collect them on the' District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of 'county pi city plan check application formto district copy for all waivers.'. ,
Embossed Original-' Building Dept./Applicant Copy-"Applicant/Receipt .� Copy =Accounting
'V: - d r