9602-150 (SFD)LICENSED CONTRACTOR DECLARATION
C/) 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
fV W Professionals Code, and my License is in full force and effect:
C) 0 ch License # Lic. Class Exp. Date
Lu r �1Nfi au B 12N_ jar! 7
IZ Ir
r`
Z i Date "�. Signature of Contractors+- , } " j + *-- �✓
T O w • Y Y '
F' °) OWNER -BUILDER DECLARATION
W U 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).
ce) () I am exempt under Section B&P.C'for this reason
LO
N Date Signature of Owner
ON
Z WORKER'S COMPENSATION DECLARATION
C) CL
Z I hereby affirm . under penalty of perjury one of the following declarations:
LO FZ O () 1 have and will maintain a certificate of consent to self -insure for Workers'
X w !L compensation, as provided for by Section 3700 of the Labor 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
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
Lo.Z permit is issued. My workers' compensatiori insurance carrier & policy no. are:
Carrier S i ATF,f i Nri Policy No. .626 6$594
6 5
r� 0
J(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
3 Code, I shall forthwith comply with those provisions.
l Date: (A -�• Applicant r%
�1 - 1` —
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, indemnity
{�v�o & 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)
• t _
BUILDING PERMIT
DATE 3f IJ% VALUATION $'I21,C►#4JO LOT
JOB SITE
ADDRESS l9-1%(.AisMiS.AriRW%CIRCLE
OWNER'
8NKI.,LERNI f,CiEK&,A.ISSOC.'
4196+'80AR0WALK ,2jx.
j>AiAI D SE1tT CA. 922.11.
(6 1777-770
USE OF PERMIT
j=Altli.LY li�V`ELGINcs
P11 AN
CT' C0N8T>~ LTC°t'•it'l q
PERMIT # CONTROL #
:' A1"2-1;561
27 � TRACT'.) I _i vj i:hi? t'S �r S
APN
CONTRACTOR/DESIGNER/ENGINEER
12C)Criw.t,; Sill .1:j.1 Nf3t`.f'.Citi1� &ASSIM
41.965 BiGr.1,WNWALK k212
PALM DESERT CA. 9221.1
I629;7777766 CBT,# 1.859
626.4.10 3F
r t'i t C�aS"f �ij t".+� +I 'ii f i�<`;: ION
PE'RMIT VVE ;51fJ.NIMARY
ART 154 ,Pt.f'i31J0' 4%j1.At TU4 - RESP' '701
r;0.t3S'TRUC.11 N'tft f`;
101.000418-000
S71$.50
MEr"r`RICi L FW'.-
101-000-4120-000
$131.55
(JRAI) lNt't I-•q3S
1o1,'Q(* 423-0o(+
2125.00-44 i-34?
Sq
10ECHANIC'Ai F41
101.000-4 1.-000
$53.50
PLAN r':itECK kit,t
"97,06
14.i11N1F1INO l"1' Is
101-000-419-000
$154.00
STON(YM.. i7KYN VIII . RESIC)
10("!36 -W-741 4)(M
1.11.7
ij S1 iG1 °1 lif t la. ti 1 f� f�P3 G.fj€;C"'{.i 3� 1,4708
r
MAR i , ars >� �� VITS �� 54;476M*
RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVA
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 a, MeVents
Fireplace P.L. f
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 47 f. ryff
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric .
Underground Pibg. Test
Final I
Gas Piping
PLUMBING APPRO ALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping v
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:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS .
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Desert Sands" Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 3/13/96
No. 14243
Owner Name Roger Snellenberger & Associates
No. 79190
Cit, La Quinta
Tract # 23913
Street Canterra Ct.
Lot # 27
Type of Development Single Family Residence
Comments
By
APN # 604-263-004
Jurisdiction La Quinta
zip 92253
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.
P,
Fees Paid By Roger Snellenberger & Associates Telephone777-7-766
Name on the check
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,465.80
Signature ID
g V CN. --k � 2, n6's D' J eve A/% .dam
Check No. 11437
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