0309-222 (RC)t 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
416304 /� C:i9 IBC: 12id lf2t
Date �' / r f Signature of Cohtracto
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.
(kf) 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 STAT1< .nMI, Policy No. 509-169
t (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.
Ddfe:, - ✓ Applicant % -� �� '� '.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
I 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
r 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) �•�l !J r _ Date 1
BUILDING PERMIT PERM0
LPa►—a.
DATE VALUATION LOTTRACT
JOB SITE APN
ADDRESS 77-•750 AVENUE N) _
OWNER CONTRACTOR / DESIGNER / EN INFER
LA QUW,A COT W RY CT..L11,,. RrJTIWN CONST'.f ICTION
77.750 54th Ave. 577S .RWH IDLL WAY
I.,A.QU'KrA CA. 92253 YORBALZMA CA 92885-11
'(714)993-3320 MIA 03819
USE OF PERMIT
CO)ANU CIAL
CLOMIW- 418 Sr .FT. CONVERSION OF CART BARN SPACE TOEXERCFSE
ROOM FOR. I. Q= 2001 CClMS.
CONTRACT AMOUNT 1035.00 1.5
ES"iT, COL ED COSR7 OF COHVXHUC"I ON
4�rn�.0a
Pit'M- rr.YEtS gIJIl: ARY
PLAN C3I,t; K FEE
101.000-439.318
�117.IlQ
C012STRUCTIO14 FEE
101-000-44 8-000
$180.00
MECHANICAL FEE
101-000-421-000
$19. so
$L9CTPJCA1, f?FZ
101-000-420-000
$23.36
Si`tl.ONC3MOTION } - RES1D
101-000.241m000
$1,64
F
eSO
EP 18 2003
CITY OF LA,
AN.19 PF.." CM-W.M.
t. -23 M..-PA1D FEES
Vitt
.$0.00
RECEIPT I DATE ' � I BY � � � I DATE F NiLED� INSPECTOR //e—
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 Wrap
F.A.U.
Framing —
f% - ;t
Compressor
Insulation
s"z _p3
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
.Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas It
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
COMMENTS: r:', �Ay��1'.Rz rJRI/ S
T?,-r o'c it-ti''3l
pAP/p C.:�/Jy Ole
_
`
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)
CERTIFICATE .OF COMPLIANCE
ss Fa
Desert Sands Unified School District
4� V
47950 Dune Palms Road
g
Q' BERMUDA DUNES r ,
Date
9/18/03
`,� q
La Quetta CA 92253
7
Gn RANCHOIAN WELLSMIRAGCJ
� INDIAN WELLS
No.
24997
(760) 771-8516
DESEFrr
PALM LA QUINTA �Vy _
�INDIO
® .Y
Owner
La Quinta Country Club
APN #
631-390-004
Address
77750'50th Ave
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit #
0309-222
Tract #
Study Area
Type
.Residential Addition
- No. of Units .
1
Lot # No. Street
S.F. Lot # No.
Street S.F.
Unit 1
77750 Avenue 50
418 Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments
'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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the above -named owner is exempt from paying school fees at this time due to the following reason:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65905 Et Seq.
in the amount of $0.00 X 418 S.F. or $0.00 have been paid for 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 Exempt - Bert Ruttman Check No.
Name on the check Telephone 714.903-3320
Funding Exempt
By Dr. Doris Wilson
Superintendent
Fee collected /exempted baron McGilvre Payment Recd $0.00 71
t �� v,' /n / 1e Over/Under
Signature
u
NOTICE: Pursuant to Government Code Se on 66020(d)(1), this will serve to notify you that the 90-day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building .DepartmenUApplicant Copy - Applicant/Receipt, Copy - Accounting