9902-115 (AR)LICENSED CONTRACTOR DECLARATION
I rdireby 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 #tt Lic. Class Exp. Datenn hy
Y238
,Date /' Y Signature of Contractors
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).
() 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 ( ) 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:
CarrierPolicy No.
Ea�rrc¢ a
(This section need not be completed if the permit valuation is for $100.00 or less).
i( I certify that in'the performance of the work for which this permit is issued,
Irshall 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 provisioons of Section 3700 of the Labor
Code, l shall forthwith comply with those rov cions.
P Y P
Date:'% ,,.' f� 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
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 for/inspection purposes. f +t
vSig ature (Owner/Agent) -• �/+ �/ `' 'S Dater a f
PERMIT #
BUILDING PERMIT,
DATE r 1 VALUATION W,,4 9
J.(10 LOT TRACT
JOB SITIf
ADDRESS c5.'• "9�� INV�!iIINF.'SS
APN 769,-361-051.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ALBERTA DIMBAS
`H ATIS f' CONCEPTS
'54934 fNVEKNJ.SS
821,23 lair'.. Ct\.RREON BLVD.
LA;QIU)NYA. (':A 92253
IN1IC) 0,A 92201
fit 0)_ d2-5555 CBL9 1461.
USE OF PERMIT
e0 SX, ADDITION TO MA5'I;.a-`i. Z SUITE •
CUSTOM COttiiSIMU..CTION 70.00 03
d 9TI MATED COST OF COTN'S"RUCTION,
'1ro'ERAUT FEE SIUMti9.rt.RY
i'1./1rf (�:HEc::�f.'�.U, $i�;-O�t4d-4:f -:31tS $54.65
CONISTRI JUCTON FFR 10-000-41"00
1si;1K°` RICAL FER 10.1•-000-421M'00
a`I`RQKG MOTION FU. -. Rh -SI 3 10. -000-241.-Ott $.S5
x
SUB -TWAT, (;0NSTRUC7tQN AND PLAN Mi -FG -K.
,� LE, SS 1.r:-.1'11.ID FI.ES
T'+i✓.�ifl.
TOTAL P.H.�AIIT ��EE.S 1)UC NOW
$15 .65
MAR 0 5 1999
e,
t. 3I TY®r �
QUI
R% EIPV1
DATE
By I
DATE FINALED
INSPECTOR
INSPECTION RECORD
t OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 4
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
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
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROV S
POOLS - SPAS
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
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:
-
Coachella Valley Unified School District
P.O. Box 847, Thermal, CA 92274
(760) 399-5137, Ext. 235
This Box For District Use Only
DEVELOPER FEES PAID
ARPA:
AMOUNT: RCPT #:
CK #: CASH:
D TIALS: DATE:
CERTIFICATE OF COMPLIANCE
(California Education Code 17620)
Project Name: Date: February 24, 1999
Owner's Name: Phone No. �
Project Address: 54-994 Inverness, La Qu i nta , Ca 92253 PGA
Project Description: Room Addition
APN: 769 361 051 Tract #:
Type of Development: Residential XX
Commercial
Lot #'s:
Total Square Feet of Building Area: 70 Sq.Ft.
Industrial
Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement
under penalty of perjury and further represents that he/she is authorized to sign on behalf of the owner/developer.
Dated: � -9 Signature:
**************************,rt***-**********4*****trtr*****,r**,t***,t********
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code
Gov. Code Project
17620
65970 Approval
Number of Sq.Ft.
7n
Amount per Sq.Ft.
$ -0
Amount Collected
$ -0
Agreement Existing Not Subject to Fee
Prior to 1/1/87 Requirement
Note: Pursuant to AB -181, any room
additions for 500 sq.ft, are exempt from
develnner fees_
By: Foch "Tut" Pensis, Assistant Superintendent Administrative Services
Administrator in Charge
Certificate issued by: Marcel a Valdez Signature:
Facilities Clerk
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this District provide (1) a
written notice to the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day
period•to protest the imposition of these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the
Government code and other applicable law, this Notice shall serve to advise you that the 90 -day protest period in regard to such Fees or
the validity thereof, commences with the payment of the fees or performance of any other requirements as described in section 66020 of
the Government code. Additionally, the amount of the fees imposed is as herein. set forth, whether payable at this time or in whole or in
part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date hereof.
CITY OF LA IN I A aVert.vtro i no►t. i vn `s.� r
• '. "� �• �s �_ D� 8�4s BUILDER sIE,PHEN �' .t>�►f.�-o/Sohn=.
IOB ADDRESS ' �¢ 1 t`I. ki :2.aJaSS PERMIT NUMBER °// 2—«� OWNER ��
nim form shall be posted an utjob with the Building h m mdien Gard at times ti a cart:nlataus place. Only persons appearing on this fist or their employees are Buthorfied to work
M Ihis job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result In a stoppage of work andlor the voidanceol
bl se
of buildingpermit. For each applicable trade, all information requested below must be completed b applicant. 'On File' is not an acre to a re
Trade I Classification Contractor Sum Contractees Limas WOekLwms
Company Name ClaseYkaden Ucomm Nwxbw Exp. Date Cadet Narma Poky Number
49.9. A. S. C-0laxaxxxl Ixx/xx/xxl 1e.9. Stam Fwd. CslCoewl (P•m+at Vatieal
Esp. pate
(xxhuclxx)
Licome NWabw
Ixxxxl
Exp. Date
Ixx/xrlxxl
EARTHWORK IC -121
CONCRETE IC -0)
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5280
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2.9 -OUR
STRUCT. STEEL IC -511
MASONRY (C-291
PLUMB"Ic•36)
LATH, PLASTER IC -351_
DRYWALL (C-91
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5w% WMT GIi
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C{, wo A Nr't; Ills rr 12219
12 9
1401
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I2-11-95
MVAC (C•20)
ELECTRICAL IC -101
ROOFING (C-39)
D%T 4j*y&WIAL
i?%gw1� •
C-10
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Ills
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ppq
S 23-J9
BMW METAL IC431
FLOORING IC -161
GLAZING (C-17)
INSULATION IC -2)
13Jqq
SEWAGE DISP. IC421
PAINTING IC -331
ppp
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12 f/
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CERANUC TILE IC -541
CAW*TS IC -e1
FHWANG IC -131
LANDSCAPING IC -271
POOL (C -b3) t 1 1 -- -
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