0109-098 (AR)LICENSED CONTRACTOR DECLARATION
VCR I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
�: Professionals Code, and my License is in full force and effect.
p 5 rrj License # Lic. Class Exp. Date
767086- B HIC - 8!31/01
~' Z ti Date- Signature of Contractor
O,O
tp �
F°_' OWNER -BUILDER DECLARATION.
J b•. C
LU W: 1' hereby affirm- under penalty of perjury that I am exempt from the Contractor's
~ U); LicenseLaw for the following reason:
Z (:) 1; as owner of the property, or my employees •with wages as their sole
compensation, will do the work, and the structure is riot intended or offered for
dale, (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)'.
M O 1 am exempt under Section .. B&P.C. for this reason
N
D;ite Signature of Owner
O�
V Q WORKER'S'COMPENSATION DECLARATION
o I hereby affirm, under penalty ,of perjury one of the: following declarations:
` ( )Lo
' I.haVe and' wilNnaintain a certficate of consent to self -insure for workers'
X U1 compensation;, as provided for by Section 3700 of the Lafi6r Code,- for the'
mJ; Q` performance of the work for which this permit is issued..
Q () () I have and will: maintain workers' compensation insurance, as required by
Q V 'Q' Section: 3700; of, the Labor Code, for the performance of the work for whldi this
�__
pertnlf
is.
s Issued My Workers' compensation Insurance caner &.policy rw• are:
d Z_ Camey' AMERICAN CASUAL Policy No. WC247859437
r CY
'. Q (This section need'not be completed if the'permit valuatiori is for $100:00 or less):
() I certify that inthe performance of the•:work• for which tFiis permit is Issued,.
shalt not employ person in any manner so as to become subject to the'
workers'' cormpensation laws of Cal'Ifomia, and; agree that if I' should- become
subject to the workers' compensation provisions: of Section 3700' of the, Labor
In Code, tshall forthwith comply with those provisions.
Date: 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:costof compensation;. damages,as provided`forin Section3706
of the Gabor Code, interest and attorney's' fees. '
IMPORTANT Appfication is hereby made to the Director of Building and Safety
for ai permit subject to the conditions and restrictions set forth on- his'
application. .
1'- Each. person. upon whdse behaff'this application' is made & each person at
Whose
req and' for whose Uenefd work. is performed under or pursuant to
permit issued' as a result of this applicaton agrees to,,& shall, indemnify
& hold harmless the City of [A Quints; its officers agents and' employees'.
f� Z.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. t agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives ofAhis City to enter upon
the above-mentioned property for inspection purposes,.
_. Signature_.(Owner/Agent)- _ Date
BUILDING PERMIT PERMIT
01
DATE VALUATION LOT TRACT
540X0DO
JOB SITE I
APN
ADDRESS 55-555 PEBBLE BEACH
775-130408
OWNER'
CONTRACTOR / DESIGNER/ EN 1NEER
RAY HENRICKSEN.
CONSTRUCTION DESIGN SYSTEMS INC
55-555 PEBBLEBEACH
P. O. BOX 628
L.AQULNTA CA 92253
LAQUINTA CA 92253
(760)771-3593 CBL4 5830
USE OF PERMIT
RESIDENTIAL ADDITION .
370 S.F. OFFICE ADDITION AT MASTER BEDROOM; MISCELLANEOUS
REMODEL PER APPROVED PLAN
CUSTOM CONSTRUCTION 710.00 SF
VALUATION 1$967.00 LS
EST13U=. COST OF CONSTRUCTION ,_
40,01M.W.
PERMIT FEE SUbI ARY
PLAN CHECK FEE 101-000439-318 $260.89
CONSTRUCTION FEE 101-000-418-000 8349.50
MECHANICAL. FEE 101-000-421-000 819.50
ELECTRICAL FEE 101-000-420-000 824.45
STRONG MOTION FEE - RESID 101-000-241-000 84:00
GRADING FEE 101-000-423-000 820.00
SUB TOTAL CONSTRUCTION AND PLAN COCK
$.6-79.34
LESS PRE -PAID FEE
$0.00
TOTAL PERMIT FEES DUE NOW
$678.34
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/
Underground Ducts
Forms & Footings
A1419
Ducts
Slab Grade
Return Air
Steel
Roof Deck
O.K. to Wrap5%/
// 0/ (
/
Combustion Air
Exhaust Fans
F.A.U.
FramingCompressor
Insulation
�!�d� b
Vents
fireplace P.L,
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall .Firewall
Exterior lath
Drywall -Int. Lath
Final
BLOCKWALL APPROVALS
Final
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
COMMENTS:
�/ ��� ��dIOI�
'
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)
Bin # 4
n
8
City of La Quinta
Building 8r Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Trackirg Sheet
Permit #
Project Address: 59.555
Owner's Name: I ) 5AN jQI G
A. P. Number:3 _
Address: s 5 SS f 1
v
Legal Description:
City, ST, Zip: (A
Contractor: G#>S OVh N
Address:
ne:•
Telephone: h0 S
Project Description:
City, ST, Zip:
XY45A SA rr5 2-9 �.
Telephone:�i
ALSO � �L
State Lic. # : CityLic. #:
Arch., Engr., Designer: p
Address: 62-- 72-3 D8 0 -
City, ST, Zip:
Telephone:
n Type: P
e: Occupancy:
ane
Y Constructi��,Z5
v
Lic. #:
Project type (circle e one : NewwState Add'Alter Repair air Dem o
Name of Contact Person: S 1` ..rO.....
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: D op
l APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
} u
Plan Check submitted
9114c',
Item
Amount
—Structural Calcs.
Reviewed, ready for corrections
12
Plan Chedc Deposit
Truss Calcs.
Called Contact Person
Z'
Plan Check Balance
p2,
Title 24 Calcs.
10 pl ,
I Plans picked up 77
L6
Construct on
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Review, issu
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
"' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
/
0!
Total Permit Fees
�(7 •3
57 Tb g�NL 3) ?
Notice:
Document Cannot Be Duplicated
Date 10/4/01
No. 22560
Owner NameRay Henricksen
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA, 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN# 775-130-008
Jurisdiction La Quinta
Permil #01097098
No. 55-555 Street Pebble Beach Log
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 270
Type of Development Residential Addition Na of Units 1
Comments
ion is a 270 s.f office addition at master bedroom.
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 folL)wing reason:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant io Government Code 5308.0 in the amount of
1
0.00 X 270 or $ 0.00 the property listed above and.that build ng
permits and/or Certificates of Occupancy for this square footage in this pfoposed project may now be issaed
Fees Paid By EXEMPT - Mike Evans ":'telephone,. 760--578-5191
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow *Exempt $0.00
1 Check No.
Signature . fW
W w
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9D -day approval period in which you may protest the ?ees or other payment identified
Dove 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
)llect 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 - Applicant/Receipt Copy - Accounting
YOUNG ENGINEERING SERVICES
Engineering Architecture•Surveying• Building & Safety Services
Letter of Transmittal
To: City of La Quinta Date: 9/21/01
Project: PC# 0109-098 (1" check)' -
55 -555 Pebble Beach
Attn: Greg Butler W.O.:
Tel No.: Tract No.:
We are forwarding: X By Messenger By Mail Your Pickup
No. of Copies Description:
1 Plans
1 Structural calculations
Comments: No structural plan check comments. Plans are approvable.
P.S. — Check new partial height masonry fire place for minimum 2" clearance from.
any and all combustible materials. Refer to sheet 2.
This Material Sent for:
Your Files X Per Your Request
Your Review Approval
Checking At the request of:
Other
By: John W. Thompson
Phone # 760-342-9214
47-159 Youngs Lane, Indio, CA 92201 (760) 342-9214
Bronz Young
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY O FIRE PROOFING
❑
❑ OTHER
�d
JOB•L`Oc O r _ n' �I _�
J�
/ V
REPORT SEQUENCE NO.
TVP F - 11�j UREA '.
CCi,�� 1� e
_`-.-_--_...-._�
./ IT N/\0
o
OA�Ey
a/
DAY OF WEEK
MATERIAL DESCRIPTION-
ARCHITECTV
ILI TOR
L
HRS. CHARGED
/
ENGINEER
S� l n
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL
DATE CONTRACTOR ,.�-- ----
SUB
- - ---,=CONTRACTOR-
Cd tj -Die
COPY SENT TO CLIENT O
CONTI ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MJ
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
�
J' ---�
GNATURE OF REGISTER6 INSPECTOR
o ��0 &I
D TE OF EPORT REGISTER REGISTER NUMBFRR