9602-146 (SFD)cn LICENSED CONTRACTOR DECLARATION
N U) I.hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W ' Section 7000) of Division 3 of the Business and Professionals Code, and my
o =M License is in full force and effect.
I- W License # _ Lld.. lass] U Exp. Oahe 12 V97
fl -Z Date w_ / Signatureof Contractor ca ! (_ ��/ ; , I (I
CD P d) OWNER -BUILDER DECLARATION
J I hereby affirm that I am exempt from the Contractor's License Law for the
CL
W following reason:
U) () I, as owner of the property, or my employees with wages as their sole
Z 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
LO Date Signature of Owner
N
OU rn WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
o g Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
r 0 compensation, as provided for by Section 3700 of the Labor Code, for the
X w LL. performance of the work for which this permit is issued.
Q J _J () I have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
Q U permit is issued. My workers' compensation insurance carrier & policy no. are:
a rn Carrier Policy No.
? Z (This section need not be completed if the permit valuation is for $100.00 or less).
r O () 1 cemfoNatlili tAYperformance of the work for whidi is`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..---
4Date: %!• Applicant !i
Warning: Fail ur io 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 application agrees to, & shall, indemnify
& hold harmless the City of -l- an- RYWiZ of Z,e , 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.
f
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) ' (. �4 t t � 1..C.� i Z—Date:X�111001,�
P
"""
BUILDING PERMIT
PERM'T.
DATE3/ 1/96
VALUATION S121.684.10LOT 23
TRACT 2391.3 P41A.S113 IV
JOB SITE ADDRESS
APN
l
-, '0_ VA • .PfI A If I X1,119
6i.i..11
OWNER
CONTRACTOR
#4 it/i SQ`
11�8�65
41865 I, 0.A111)WALK 012
: 1'A.I,.M0ESh11cr CA 9221.1
C'.tLl; M DFS'EU CA 92;1.1
I I Oa�yry ^r r:'6 r cu
DESIGNERlENGINEER \
'61917774-1766
USE OF PERMIT
LJNGLE .11011, L. WL:L1.,1NC
tit IA17'L•IMA.
PLAN 1
FEE DESCRIPTION
FEES
*VRAk t' C0NS t2tlC17.«N .. U15,t1ij SF
GARAGFICAR.i'C">111' SF
'ENTIMNIt 1+,I) COST OF CONST:IfLrMON
121,684' 30
P1+ RMIr €'EF. SUMMARY
PLAN 01RCK FEE, 101.000-439-3I9 $597.06
CONSTRUCTION F..EH .101-000-418-000 $716.50
ACCHANICAL 1•11 101-000-421.000 833,50
EI:ECTRICAL BRIE 1014400-.820-000 $131.55
C�
PILLM{3r1.rQ FFF 10 - 7-a1 5154.09
Q rn f
S TNG M0,111'ON FEE - RESID 101 -WO -241-000 $12.17
GRADING :FFH 101.000-423-000 $20.00
o
INHLASTR:L+C'1"UR FE'R 225 -OW -443-.342 $2,':37.89Q(
ART Oa 1si:: ILIC PLACES - RESM 701-000-235-000 S54.21�
�
m
S_U-8--rq'IAt CDNS"I'RUCTIGN .AND PLAN CHECK
U,476,88
LESS PRE -PAID FRES
$0.00
TOTA1:, PERMIT'; EES J VE. i'NQW
$4,476.88
RECEIPT
DATE
BY
DATE FINAL ED
INSPECTOR
d
Z.
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 WrapF.A.U.
Framing
Compressor
Insulation L
Vents
Fireplace P.L. f I, U
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath t
Final
Final
BLOCKWALL A PROVALS
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 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
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:
'
f
Notice:
Document Cannot Be. Duplicated
Date 2/29/96
No. 14186
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Roger Snellenberger & Associates
No. 79195
City La Quinta
Tract # 23913
Street Canterra Ct.
Lot # 23
Type of Development Single Family Residence
Comments
By
APN # 604-263-008
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area 233
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
Name on the check
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Telephone- 777-7766
Payment Received $3,465.80
Check No. 11318
Signature
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