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LICENSED CONTRACTOR DECLARATION
I hereby 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 # SLiic. Class Exp. Date
Date A h 0) Signature of Contractor l ^ • + "" '" +
1� r -- - � ax -• -. _..tip v _, 4.
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 ownerof 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 Sigriature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm, uh*6er penalty of perjury one of the following declarations:
() I have and will maintairiia 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.
W 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 ;rT'#�"�'i!7UN +j Policy No. 620? S9i
(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 those provisions.
Date: r t •�f r} Applicant �,J!
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 i.
correct. I agree to comply with all City, and State laws relating to the buildini,
construction, and hereby authorize representatives of this City to enter upoi
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �� ?� i j Datef�
PERMIT # CONTROL #
BUILDING PERMIT 3140
DATE 41,7196 VALUATION $140,657.30 LOT. � TRA T
JOB SITE
ADDRESS Ft�••4g��� CANT 1,anu 17 F: V
OWNER
CONTRACTOR /DESIGNER /ENGINEER
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LA Gt1(N1 A C.A. 92253
LA QYU1NrA., CA 92253
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USE OF PERMIT
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PLAN r: }s1?cN; —11FIi
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CONSTIMR:1110,14 1*031 1101.000-418- $783.0
&W-CRANiCAL FIT: r.su
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A1r.r 0.4 V11131,ILr f-11,ACNS - ft_11811' 70-1.00 -255-4)00 $10G64
al a
SJf :ODT,AL C0N*"T' WC°1' ON ANU PLAN CHECK
$5.134.77
LUSS• PR -PAJD F.RE,C
SO.00
'I TYCA L 'PI<s' RM,!" �' ti`EE ..VIUE NOW
55,1:1;4.77
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
ox
Drywall - Int. Lath
IJ
Final
Final
POOLS - SPAS
BLOC KWALL APPROVALS
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 tines
Heater Final
Water Piping
Plumbing Final
Piumbing'rop 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
Fndures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) i
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 4/17/96
No 14333
Owner Name Roger Snellenberger & Associates, Inc.
No. 79080
City La Quinta
Tract # 23913
Street Canterra Dr.
Lot #
Type of Development Single Family Residence
Comments
APN # 604-261-009
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area 228
Square Footage 2359
No. of Units 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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.72 x 2,359 or $ 4,057.48
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 Roger Snellenberger & Associates, Inc.
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature Pna 1-4 ,QQ M a V c 4 A I A XI ,P/1"k-
Teleph6ne , 777-7766
f \
Payment Received $4,057.48
Check No. 11830
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