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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 # Lic. Class Exp. Date
}Date 3 "14 _ 9tQ Signature of Contractor k !
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 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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under ,penalty of perjury one of the following declarations:
() I have and will maintain a 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:
( ) 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 �T.CA7fjj F(JNI) Policy No. 626345594
(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,alshaI forthwith comply with tfpose provisions
Date: • tl� 1?1& APPlicant 1 i .+.. L9 4 t - C. iJt 4"
w 4
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 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 ehter.upon
the above-mentioned property for inspection purposes..
,Signature (Owner/Agent) f�'f`''�"' Date�t�
PERMIT # CONTROL #
BUILDING PERMIT 96112-149 2945
DATE J/ 1196 VALUATION 1 Z 1,fiR41 to LOT 3h TRAM a�� 1 � ,1y1=I t1ti1's 1 V
JOB SITE ADDRESS � 1 '�.f � / Z.�. e�.
APN 04-263-019
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RYY, {i ti`Ai}d Jf31'TR �+ C. C'!'`j1�i
/.0. R,:/L.t J,n �i L.J VA+7-: 1;s3."l� W1 4\\IAe� O:V. t},J,�I.f\./1:;.
"Cf -1 f,`' CA11.1 'j i ti>►., "'r;'l3 Qr l� Cr4'f•
,I.w\�/l./,ye `M1 �IIVOe 116J �,r14'l.Jb/�.��J.+)�. 0.M 11.1 �\k6./'•..r.
41965 F30Ait,E)W A1.R 9.212
!'ikLkl fXisp1t r t*A 92211
PAI.... DE.S1 •K'1
tCl l�`17.7'7t�c.
#ii19_777-7 66.. C;8 Uf 1.8-58
USE OF PERMIT
• r
626 09) 3#'
psumvaco cosT ori CONSTRUCTION
U1,684,10
PE'RNll}t"i' FEE SUsi9.::NINkV
MRT P4 PUBLU ;.;?1.ACAS RYTiSil" 70.1 -Mt ,15., 000
0 1 1:{' t1 i? "i".i0.1 d FEE 101-000-418-0,90 X7100
gi i4'C't'1t1CAL CRE X107-0150-42fl-tW $131.55
otm,)[No FEE
04F€tA;$7'RUC7`1. E ? -13 275:,{ M-443-312 $2,737V
ftiWIC-11.AWAGIAL FEE. 101-000-421-000 5x.
41LAN 1',1-11 C�K.MEH I WG 110-1139- 31 3 t597,w
PLUM431NO M 10:1.000-419403 $154.00
V1{WW1 MCJTION, 14W - R1 3R) tO.A-OM '211,1. ) 0 0 $1.2.17
U.S. r r i . a14S1'Tvn1'1%N AND' a a .MN CIRI CK
$4,47 -1348
LE .'t I -PA.ID FEtSs
�gg6
$0.010
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation 8
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWAII 4PPkOVALS
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 APPROV LS
Gas Test
Electric Final
Waste Lines
Neater 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 PPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Servico
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final rP
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. 14242
Owner Name Roger Snellenberger & Associates
No. 79200
City La Quinta
Tract # 23913
Type of Development
Comments
Street Canterra Ct.
Lot # 26
Single Family Residence
APN # 604-263-005
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:
By
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 Telephoine 777-t',66
Name on the check - �-
,,i
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,465.80
Signature k � PQ &A
a e
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