9602-152 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F' Chapter g (commencing with Section 7000) of Division 3 of the Business and
CV CO Professionals Code, and my License is in full force and effect.
E; :D (h License # Lic. Class Exp. Date
O LO488233 B 12/30197
Z � /Date Signature of Contractor
O � i- -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the 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).
co() I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
CL
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LID FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu �L- compensation, as provided for by Section 3700 of the Labor Code, for the
mJ JQ performance of the work for which this permit is issued.
Q I have and will maintain workers' compensation insurance, as required by
O C Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
LO Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No. tilti.Siy1
co 5
r, a
Q (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:.,�= Applicant f ,1, i rff ,. f»•2-.--
'Warning: Failure to secure WorkersCompensation 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.
Signature (Owner/Agent)�` �• f 4:: -' �'- Date
BUILDING PERMIT
DATE +♦l�j� VALUATION S121,6".111 LOT
JOB SITE
ADDRESS 79-170 CAN'1 EEK k CIRCLE
OWNER
41865 BOARDWALK 6212'
PALM DESERT Cry �1f211
f 61 n 1777'.. 77M
USE OF PERMIT
S[NGLI' FAWLY DWELLING
QUINTHRiA
M,ANJI1r-
r
<',fAtt Ac.11:li:Ak1:F'Litt't'
'1' tAk4--' f'0h15'C121JC7n(,-N
PERMIT # CONTROL #
9602_1.2 2948
:604.2(.5-002
CONTRACTOR/DESIGNER/ENGINEER
RGCES: SfidEI,LHNI F13FAGI:tt & ASSOC.
41965 HOARDWALK #212
PALN4 DFSHR:l' CA 92211
i A91777.7766 C81.0 1859
h`:6.iW1 tits
2,015011 Sr
S0111-R)TAI a` 'S l'[ U(:t'tON AND Pj...-1;N cua h
�gg6 LESS, PRE -PAID FEES St7.iK,
O MP�1 '1' 1•t 1, PFRI1t'i' FEEN 1101, NOW 54,476,89
PERMIT PEP, Si)MMAR
r J?T 1N Pt JIAI,H: PLAC13.'I - R13S11' 701J9.10 -254.(X!(1
(; 011:;1'12 if:11601,;
t01-011-418-000
$7 tt5.4t)
t:1.,FC'i`ItiCAf.1 fifi
li/l tHiCt-•12itl t
i:i1.5;
ORA LINO FEE
10t-OfN?.ql:;-1)!11}
$20,00
1tJi 12 ¢ °{ I tt 111'"t l iit.l? lrltf
1; 5 fl()ti dd i-i.t?
$'1737 ftp+
NIIiCIIAINICAl FEN
:91-000-11;1.1-000
S51,A)
N.Atti t;iliik;X i-fil
SSv;.ti6
Nl,f 1111{INi 1 1,)..1.
1011401-+419.000
315.4.t>tt
:1'l'+' N a RIM1014 N1.4- , ftl,'Slll
I(}I-(X10.1141-(991
SI1.17
S0111-R)TAI a` 'S l'[ U(:t'tON AND Pj...-1;N cua h
�gg6 LESS, PRE -PAID FEES St7.iK,
O MP�1 '1' 1•t 1, PFRI1t'i' FEEN 1101, NOW 54,476,89
INSPECTION RECORD
OPERATION
DATE
I 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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
I AV
Final
Final
BLOCK -111`01 L PPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING AP,,PRqVALS
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:
(
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 3/13/96
No. 14245 Jurisdiction
Owner Name Roger Snellenberger & Assosciates
No 79170 Street Canterra Ct. .
City La Quinta zip 92253
Tract # 23913
Type of Development
Comments
By
Lot # 29
Single Family Residence
APN # 604-263-002
La Quinta
Permit #
Log #
Study Area 223
Square Footage 2015
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 2,015 or $3,465.80
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 `. Telephone X777-77.66
Name on the check
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,465.80
Check No. 11437
Signature "� est pu k11.i1�,�'✓�—
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