9801-0068 (AR)48850 Avenida Anselmo
xLICENSED CONTRACTOR DECLARATION
I hereby<affirmnTinder penalty of perjurythat 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 a d effect.
License # Lic. Class Exp. Date
690405 131 (.)/W98
D to !" _ ignature of Contracto( 1 ' 'k' ' • / ✓J or(- y
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 Policy No.
:: CA`rfi 1-1 tiro 14- i-1849.)1*579
(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. r'
,bate: r - a. f 1> Applicant
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 enter upon
the above-mentioned property for inspection purposes.
,Signature (Owner/Agent); e, - / 4,_ --c/ Date
$f / .IGDING PERMIT PERMIT#T ICONTRROC#'-
1
DATE VALUATION . LOT TRACT 6-743
JOB SITE' r APN
ADDRESS 4 A.V ENI DA ANSELMO 01-331•A4i'r
OWNER CONTRACTOR / DESIGNER / ENGINEER
NFIL WALLAC:H CLASSIC" RULMRS
48IS.90 AVENIDA ANSEL") 43-270 CLUB DkiVF
LA OIJINCA CA 92251 INDIAN WENS CA W210
(760M2.1011 ('RI,N 44")
USE OF PERMIT
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LESS PIZE-PAID fTES
16,444.20
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CIY A1. PERMIT t VEN DUE NOW I $413.04
F IIIIIIIIVIIIIIIVIIIIIII 43
IE
RECEIPT DATE BY' DATE FINALED` INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & rootings
Ducts
Slab Grade
Return Air
_
Steel
Combustion Air
Roof Deck
Exhaust Fans
t�.
F.A.U.
Framing
Compressor
_
Insul +
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath _ f
'
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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 Test
Electric Final
Waste Lines A
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) U
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors _
Powerp s 3//y
Temp. Use ofAA
Final
t93ilify Notice (Perm)
COMMENTS: /
G`br�7 %��!fL J�dG /�C�lltyjil/ G�C/LDI%.
7 ",
r
Desert Sands Unified School District r
82-879 Highway 111 ������� 11111 111 11111 Jill 44
Notice: Indio, C 92201 1E
A .
500
Document Cannot Be Duplicated 619-77A 922
CERTIFICATE OF COMPLIANCE
Date 1/21/98
No. 16529
APN # 631-331-006
Jurisdiction La Quinta
Owner Name Neil Wallach Permit #
No. 48850 Street Avenida Anselmo Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 331
Type of Development Residential Addition
Comments
imng room addition
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:
Residential Addition 500 Sq Feet or Less
EXEMPT
e ,
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 331 or $ 0.00 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 n/a
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Pauline Pearson
Signature & A�L" ft)o A I A- A
Telephone 772-1011
Exempt $0 00 ,
Check No. n/a
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
Dove will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
Dllect them on the District('s)(s') behalf, whichever is earlier.
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
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