9511-129 (AR)A�
Ciiii;LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
oL M Section 7000) of Division 3 of the Business and Professionals Code, and my
t` Q LO License is In full force and effect. 366-A5 C$. 11/3D/�C
r` W License # Lic. Clas . Date 1
rCr Date SignatureofContractor� J�. )< A& . , ra.
GSP 6 OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
0_ following reason:
Z (. ) 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 licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code).
( ) I am exempt under Section B&P.C. for this
co Date Signature of OwnerLO
N
CIJ
O WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations: ~
C)M Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
� H OM compensation, as provided for by Section 3700 of the Labor Code, for the
X W LL performance of the work for which this permit is issued.
p J J ( ) I have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
p U permit is issued. My workers' compensation insurance carrier & policy no. are:
aLO H Carrier &i.'AT.1311fND , Policy No. 112255182
_Z (This section need not be completed if the permit valuation is for $100.00 or less).
n =)() I certify that in the performance of the work for which this permit is issued,
d 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
1 � P
Code, I shall forthwith comply with tho provisions.
Date: Applicant �.{ii+'..�r_.-...
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, int3rest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
• ` above-mentioned property I
or I spection purposes.
Signature (Owner/Agent) il/{itr.,. _ Data
w
ALC9
-.BUILDING
PERMIT
PERMIT.f a�r1Z`°
DATE
VALUATION 0.1
LOT
TRACT
JOB SITE ADDRESS rl.066 jN y$ -NIMkR
APN 769361,047
: 1OWNER
CONTRACTOR
'
BOMCHER CONCPXM CONST.
VIC SC1:•IOL.'?1F:LD
54.415 ?ISENHOW611.OR..
55066 fNVEF.3IESS
LA I.;�(.fNTA CA 06255
LA.'QUINTA C A, 82253
6195643411 CBIA 2532
DESIGNERIENGINEER
P AI Jt, S, ANDERSON .A.TA
79-354 Vk'LIE virA` #6
USE OF PERMIT 1.r: %%1 iC;i'L'1^'i,�,lli1#1(_[)ti. 81Nfi 11U,
I.ilri IlVgPV OA W"All t'414's146-
AW) 211 S.F. AT NTPCHHN ANf.1.1 IRBAK AST #ZOOM. AU ,16 S.K TO G011 CAR -T GA.RAG
FEE DESCRIPTION
FEES
(ifi9,tll''rY;;.t11e:P0RT 46.00 ii,
CUISTOM C,O,I$YRUCTIOid 211.0 LF
Ji',!9 'T1%L,%TED COST Or COINb`$ RUCTION
17,339.50
ft,36111 F.t 3,0iUMNIAR.Y
-SU13-'l.Y rAL CONSTRtIC'I"IO.N .OM, ,PLAN CHECK •.
3
�35�3.
LESS PPM-PA1DFEES
$0.00
TOTAL PAM&1t I T'SVMSt TW INM
$350.97
TOTAL PROJECT 3":KRf4 I T FE f '
350.97 .
RECrRTS ("y
DATE }/, 7,�
BY
DATEFINALED
INSPECTOR'
Notice:
Document Cannot Be Duplicated
Date 11/28/95
No. 13919
Owner Name Vic Scholfield
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 769-361-047
Jurisdiction La Quinta
No, f5�5OC6 _______Streeter ss—
City La Quinta zip 92253
Permit #
Log #
Study Area
Tract # Lot # Square Footage 257
Type of Development Residential Addition No. of Units 1
Comments
Add 211 sq. ft. to kitchen & breakfast rm. + 46 sq. ft. to golf cart garage
1
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 257 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.
Fees Paid By N/A
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
-'Telephone 564=2856
Check No. N/A
Signature PftaA 14a Q ?, 0,Ll A 4AJn,—
E,�, 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