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9602-145 (SFD)cn LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with r W Section 7000) of Division 3 of the Business and Professionals Code, and my o = M Lo License is in full force and effect. Q W ^ License # I -A asst 11 Exp. Date 12M/07 7 r- ri \,Date -A jai Signatureof Contractor 1 �f rnZ c'o � OWNER -BUILDER DECLARATION J W 1 hereby affirm that I am exempt from the Contractor's License Law_ for the 0. following reason: r 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 reason � Date Signature of Owner N' UO rn WORKER'S COMPENSATION DECLARATION CL Q I hereby affirm under penalty of perjury one of the following declarations: g Z ( ) I have and will maintain a certificate of consent to self -insure for workers' Lo H cO compensation, as ' provided for ' by Section 3700 of the Labor Code, for the X Lu 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 00 Q U Section 3700 of the Labor Code, for the performance of the work for which this p L) permit is issued. My workers' compensation insurance carrier & policy no. are: CL rn H Carrier Policy No. `t Z (this section need not be completed if the permit valuation is for $100.00 or less). 00 :D() I ceR atirlA tQperformance of the work for whieh�th 0irmit 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 0 Code, I shall forthwith comply with those provisions. Date: ', i^ / . Applicant ; i 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... A 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 14 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 Wslls�_`its%fficers, 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. r Signature (Owner/Agent) , r I t" 1 . a �, L.,.,, Data -z.,/ I I,va ALC II BUILDING PERMIT PERM'T' DATE .1./ 1/96 VALUATION S121�684.1Q LOT 22 TRACT 23913 PHASE IV JOB SITE ADDRESS . ,,TIVIV Ili :. ". APN OWNER CONTRACTOR ROGER,S:`<fL+"U v NU1EPR re:R.cC:,.ASSOC ROG, ER SNELLENBEktG ER & ASSOC. .11.865'I�:J?�2;3�J:'Av�'i>E212 41605110AIWWAIX#212 PALM DESERT CA 92311 PALM DF8FRT _ 0.A 92211 x'77?_� r 6 is !R -,Q DESIGNER/ENGINEER (6105Y177-7760 USE OF PERMIT SINGLE FAMILY WELLING QUlNd'.ITMA PLAN IR FEE DESCRIPTION FEES 'YRAC'x' C'ONS'1XI ICTION 2,015.4© 911 GMAMCARTgORT 626.00 Sl � MTilA#`IEDCOST C3F+w":C1IVSTOV030K 121,684.10 PERMIT FEC SUMMARY �� P1, AN (.+WC.`K 1'Rf7.. 101-000-4z9-3113 �S9 r'.OF °�1 CONS'TltUMf014FEE 101-000.41£1.000 $716.50 MEP�13ANiCAL FEE 101-000411-000 $53.50 1=.:i ECI't21CAL F14 -M, 141-0004204)(10 $131.55 L #'IJCltv9JNQFE i(j1-Oni1-439-(1()i► $154.00 �' o STOiJt,MOT10,14 'E - R13a:LD 101-000-241-000 S1N.1.7 GRAWNG M", 101-000-423-M) $20.00 v� �I � fNF12AS'T`ItWTUIs8I41Y 225-000--143-312 $2,737.$9. rlli'1 ! N l'17131.T.1. '1'I,!Cl:f3 ;1Z:1v91i :3O1-()00-255-0()0 $.'1. L. d I SUB -TOTAL C..ONS RUMON ANDPLAN CRECK: $4,47 6.88 LESS PRE -PAID FEES $0.00 TOrf AL PERMIT)FEM DUE NOW $4,476.88 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 6 Return Air El 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 P OVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location b 4 Underground Electric Underground Plbg. Test Final I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines V 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 PP OVALS 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 Date 2/29/96 No. 14185 Desert Sands Unified School District 82-879 Highway 111 Indio, CA 92201 619-775-3500 CERTIFICATE OF COMPLIANCE APN # 604-263-009 Jurisdiction La Quinta Owner Name Roger Snellenberger & Associates No. 79185 Street Canterra Ct. City La Quinta zip 92253 Tract # 23913 Lot # 22 Permit # Log # Study Area 223 Square Footage 2015 Type of Development Single Family Residence No. of Units 1 Comments By 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 Teleprhone 777-7766 Name on the check Dolores A. Ballesteros Superintendent Fee collected /exempted by Pauline Pearson Signature - WA - M W E � NMI 11M� l� Payment Received 7 "%3,465.80 Check No. 11318 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