SFD (9910-212)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chap3er a' (commencing with Section 7000) of Division 3 of the Business and
i rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date 7001
D�t ��, Signature of Contractor'
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.
GOLDEN LAME IN.S. WWI nIM-01
(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 Aection 3700 of the Labor
Cod sp �. jgrt y'Yiihomply with th;;0.-s�ro
v
atais�qb�
/ Applicant i�/i
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 i spection pu oses.
Jai`.'
Signature. (Owner/Agent) '` • �. Date / ,-;
.
BUILDING PERMITPERMIT #}.k
DATE ) VALUATION $130,404.50 LOT 17 TRACT 231M -W
JOB SITE
ADDRESS I 7"45 NEXIDMIN WAY
APN F► 9-43il w0f) I
OWNER
CONTRACTOR // DESIGNER ENGINEER
AyyVTJy CROWLLCCII*pNUN .S
CERN'ruzy CROMIEU CONMI6A i'MpS .
1535 slap "D" Kntls. a, g ir; ilidid} -
15:35 So. "tY, � 11RUX-7, SIE. 9200
$X& 43fi#i.ivE1R. INO CA 9210
SA AEIi.Nxi1iT INI O CA .92408
(904})x£31 -i 0G-1 CHL4 2120
-
USE OF PERMIT
SINt�P.,.i.1'.�i'��' Y I.�i�tE,t.3, NCZ--
S - WT 11, PLAN MR. izia'?'�.�v1>t'd Dv"ZZ xv'OT MCL ME BLOC -s- Ytrr11 L GR
.tat)C7L.
'1`IZaa "T COtdS'I'.E�13C" ON Z 345.00 7W
1,10Rt�'nUPKrio 30.f1('A 317
GARAlWt`,f1RKAtT 635.01) .1W
ES'.�NUTA �ED C� OIC �.i�P��T�:i3i'�"�S�z'�T
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Pf,AN CIRMNX ME 4 (} i-¢?13��T4�� � :�8 W6.13
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iVf�c�.`.Y1r`,a�il�.;'.r?�i.t�:Z> IE3d-il[}13-+��°i•4)(X.1 t53.:it;
�,;
0.isC'7RICAL €".FTis $136.98
F'Ld,7t+ IN10Fl-7-: x134.73 .
S'?:'R0140 ANIP t 100 FEE - RESTEi 10!4W, r'741.•MD $13,04
GRADING FIX, 10
ART IN PUBLIC 1+1.AICES - RESM 701-000-255-W., &76.0)..
};►I ME .01W.R, l•Lai I E: r FFE :51,907.00
�i:�=��1•!11,,. <.:4"II�TC�.1_}�;'`.I�� .�.1�� ?7$r�k� ��`1taf'1+"
�'��74�,�j.4t
Ts,)TM, PE,,f MI IT FEES 044 ,t4i0W
53,70.41
)4U
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
" OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
/
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
--
F.A.U.
Compressor
Insulation
=rte%
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final %
BLOCKWAL APPROVALS
Final
POOLS - SPAS
steel
Set Hacks
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
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
'
,
- --
Final
Utility Notice (Gas)
ELECTRIC .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) -
CENTURY BIOMES
Century Crowell Communities
Tract a 3
Lot /
-7.
I/We, the undersigned Buyer(s) of the above -referenced lot and tract, hereby
request that I/we be allowed to close escrow prior to the installation of flooring.
I/We understand that I/we will be required to schedule a walk-thru prior to any
flooring installation and that any and all damages done to the home by my/our
selected flooring subcontractor will be my/our full and complete responsibility.
I/We also agree that both installation and materials costs will be paid prior to the
installation.
I/We understand that Century Homes will not warrant any material or the
installation of any material done by outside contractors and that any touch-up
painting or baseboard repair is the responsibility jointly of the Homeowner and
their selected subcontractor.
I/We hereby agree to deposit any funds necessary into escrow in the event a
flooring withhold is required by our Lender.
idgn4nktk'adrlcndmuklnsrppn{q� South "D" Street, Suite 200 • San Bernardino, CA 92408
1 (909) 381-6007 • FAX (909) 381-0041