9602-048 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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., 4011895 B 7/31/97
License #� r �(� �'/ C Lic. Class ri Exp. -Date
Date " (,Sig nature of Contractor 1.M Al f,Y _(y
OWNER -BUILDER DECLARATION
il
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) I, asownerof 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
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
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 for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier S1`XG :`U14L1 Policy No. 046-96 00047
(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 thoseiprovisions�
Date: 4- w7 1Applicant ` � � l r '��''t,<-•
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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. J
I certify that I have read this application and state that the`iabove information
correct. 1 agree to comply with all City, and State laws relating to the buildin�
construction, and hereby authorize. representatives of this 'City to enter upon they
above-mentioned property,for inspection purposes.
Signature (Owner/ t) t a` ' /, i fJ' '\� ` Date
ALC
MBUILDING
PERMIT
PERMIT16in
DATE irAe
VALUATIOM.,, o '` LOT
TRACT
JOB SITE ADDRESS 44-245 VALLET'A
APN 604-143-033 .
OWNER
CONTRACTOR
PURNEL. C� ONO
�+ �y a i7�
�RAir S3LF+SiI{, .i. IN
AOp,N�+S�'.ly�?iDt3C'i
688 75-1 SUMA41 �. QR,
44245 VILLFI A OP
C rHEL7RA(, C'C[°Y` ' CA 92234
LA QUIN'1 A CA 92253
1161�►)3.24-2024 C:BI.#
DESIGNER/ENGINEER ---
USE OF PERMITUJVI 11Q1'1 '
E140LOS1 3.KD CAi.2 GAiI't.AOU FOR USS AS A.1dC►136`S'' 1ft7ONI.
FEE DESCRIPTION •
FEES
BONUS 110OM 70.00 SF
&STIWIA.","..x ) COST 6F CONVI Ri1L"T'ION
PERMIT FJEC SUMMARY
PLAN O-IECK FUM 101.`000439-318 $52.65
CC?NSTRUCTIONFE 101-000-418-W $81.00
:d&,'€iAN(C:AL FT -N 101.-0D0-411-000 $1.5.00
k" XICTWCAL FEE 1,01-000-430-000 $20.95
r'UMYNNG F'ir( :101-000.419-000
3TONG MOTION FEE - RESI19 101-000-241-000 $39
SUB—TOTAL COIF MUCTION AND PLAN CHECK
LESS W FEES
o 1'4.)M111'1±,IWIT, +'ERS 1:DIX NOW
$9,00
FEe � • O
08: •
Ift 8,1996 •
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap A
F.A.U.
FramingCompressor
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
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:
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)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF'COMPLIANCE
Date 2/7/96 APN # 604-143-033
No. 14126 Jurisdiction La Quints
Owner Name Ray Gosselin Permit #
No. 44245 Street Villeta Log #
City La Quinta zip 92253 Study Area 233
Tract # Lot # Square Footage 170
Type of Development Residential Addition 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:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code,53080
in the amount of 0.'00 X 170 or $ 0.00
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.
• `�,
1 Sy l
Fees Paid By N/A Telephone`. ,324 2024
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson. Exempt $0.00
Check No. N/A .
Signature �(ie 'd iAAA DQ .AJCAA pS�
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