0006-320 (AR)LICENSED CONTRACTOR DECLARATION
' �iereby 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 # Lia Class Exp. Date
Z'
i Signature of Contractor 7r'
•r
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).
( ) I, as owner, of the property, am exclusively contracting_with licerised
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 DECLARATIOW
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 STATE FUND. Policy No. 2.291869604
(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' compensationlprovisions ofjSection 3700 of the. Labor
Cod6, lishall:forthwith comply with those provisions.
,Date: 12 i !,0--D Applicant �/✓r•. % 1
r
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 propertyifor inspection purposes.
c �
,,,Signature (Owner/Agent) � i k aye Date
I
x ..
BUILDING PERMIT PERMIT"
DATE / VALUATION LOT TRACT
JOB SITE APN
ADDRESS 49 620VISTA Be0.%fry.
OWNER CONTRACTOR/DESIGNER/EN (NEER
PAY
1.&QUt'`CIA. Cly 92M
USE OF PERMIT
A DTA10N
,AnD 106 SQ FT TO MASTER 81,7DROOM
CUSTOM CONSTRUCTION
O. L. SMVENS COWrRULnION
61400 Y UCCA RIDAV #260 .
MOP:;IWAIN CEMER CA 92561
(760)831-7439 1 1 C -3W 2484
0
1000D 9F I`
r MMU'D c0.037 OF COXf9rRUM00
8X.97".40
PLM CHECK FEE
r'
101-000-4-90-316 $79.89
EL .CTRICAL FEE
.1 Qi 000-e420-000 $$19.00
STAM10 MOTION FFZ - =1D
01 000�W -000 Lot
CONSTRUCTION PI:
1b 0®tT-�E18-0Cr0
RUB -WEAL C01`WFLUCHON AVW PT" C%)M, CK
$197.01
LESS PRE-:PAMS
$0.00
RECEIPT I DATE
BY I DATE FINALED I INSPECTOR
INSPECTION RECORD
a° OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings�,j
c�_
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
- 15 -0 o
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
q
Drywall - Int. Lath
6%p.
Final
Final
BLOCKWALL APPROVALS
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
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
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:
/ � C� C'
CL C/�
G O
v l S
Desert Sands Unified School District
•47-950'Dune Palms Road
Notice:. Lai Quints, ;CA 92253 '
Document Cannot Be Duplicated ',760-771-8515:
CERTIFICATE'OF. COMPLIANCE
f Date :6126/00 '. APN# 773-350-002
No. ,.20618 Jurisdiction 'La Quints
Owner NameParry i f Permit #
No. 49-620 • Street Vista.Boriita Log#
City La Quints - -.Zip 92253 Study Area
Tract # - Lot #' Square Footage 104 Al
Type of.Development Single Family Residence No. of Units 1
s
b
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 1 accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due tootle following reason: Rf;
y Residential Addition 500 SgTeet orLess
EXEMPT'
This certifies that school facility fees imposed pursuant'to. Government Code 53080 in the amount of. fi
0.00 X 104 or•$ 0.00, the property listed above and tha-, building
'permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid By exempt/GL Scrivens ' r +ts Telephone .760 349-3327'
Name on the check "
a
By Dr. Doris Wilson, -
' Superintendent ,
Fee colleced /exem, ted b`y Olivia Aguirre Exe Pt _X0.00
Check Na. ° N/A
`'Signature
NOTICE. Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you lhat1he 90 -day approval period in which you may ii rotest 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
tolled them on the.District('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 7l Applicant/Receipt Copy - Accounting r