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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
714118 13 ,;� _ 1/07
Date '!� Signature of Contractor
OWNER-BUI
I hereby affirm under penalty of perjuerythat 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
r -
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:
,Cartier UMi'1-1 IN.S. C.(). Policy No. 2042(*6904 ,
(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 subj ct to the
workers' compensation laws of; California,. and agree thaVibl should, become
subject to the workers' compensation provisions-oY,Secir6 3700 of the Labor
Code, •Ig9shall forthwith comply with those provisions
Date:/ �P/4"Applicant
Warning: Failure to secure Worke, o p�tion coverage is unlawful and
shall subject an employer to criminal p ne alties 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, indemnity
& 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 h
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,rand State laws relating to the building
construction, and hereby authorize' representatives of this City to enter upon
the above-mentioned property for..insp6ctidn p rposes-""
Signature (Owner/Agent), D.a - r �/"
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PERMIT # CONTROL #
BUILDING PERMIT , 961154? 3287
DATE 9�/ JJ!() fo VALUATION VM474,10 LOT j TRAC 188
JOB ADDRESS $5-{��.0 .L�.i�. DGE—C�I��.vv WAN,
APN �* � f
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OWNERK
CONTRACTOR /DESIGNER /ENGIINEER
dgpTIVIRL CO ILL C'O!SNUlTlN
CrN'TufvE4!JtFE{.31 CJNIN"WIVGICES
1535 SO.
153:5 SCJ. "17" 371tF,E1. SM. 4200
SAN ISERNAR DIN, CA 92408
SA.N D NO Cil 9W.8
(9W)381.6W7 ..
.81%1INAft
{9f-1n�.z8€ at�7 �' L ` 2120
81—At 7JAtN31i AG-1.tl•LAk ASSOC.
USE OF PERMIT
s�N� lai�'i�'A i1L °.ta�UL'�,L%t�C
54svI'A. S4lZ<:) AVE-
0.131. REY 01. LA. c1 H14TA W3W.['E
PLAN 3:CF�
•1 t1AC:1' 1.663.00 $
GARAGWYC;AfiP£?RT 417.00 4,1a
iY 2/3 11:11 i:'u li tib' i:±Gf� ; i SIL'' i &�31J
98,474.10
KAN CW_1CK VMM 101•••11f)a-0q-318
CONSTRIA-111101N.,FEE 101-000418-000 $635.00
MECHANICAL F, 101-000-421-000 353.`+11
i«i3:.ECI'tgt. AL H.k'i'i ,10:1-0004110-000 $E sms
tC�t..t
.�w . ((/)�-4q)4/y/�-�'IAv:/Q�(i?/4)� 514800
grd3f�7p/0�1{;ryr� y gry7
3.11OING =�'bC!'A; 01V 11;IL3 '° bV SID 101-000-2`{14)GO S9, J5
G[tAl�.Ii�1f3.F1{`-1s � • t0i-�ia'�-42 ��.OEi
INMASTRUC-MM 170 225,1}011-44 -3�iz S2:^�1s.es7
` --� SUR -TOTAL OTAL CC1RS't` LIC'nON, AND PLAN CHECK
$x,730.23
0 _ LESS PR -PA iD FTE- S
L,J -
$Uo
1'�1 A Y 0 •; TOTAL PCRME �' FENS 0Eft NOW
SJ.730,23
J ,��08
1
V/
RECEIPT
DATE
BY
DAnTE F ALE
INSPECTOR
INSPECTION RECORD
OPERATION T77;ATE
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 am
F.A.U.
Framing
Compressor
Insulation 1'Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final/K holy
BLOCKWALL ROVALS
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 APPR VALS
Gas Test
Electric Final
Waste LinesHeater
Final
'Water Piping—AY
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)
ELECTRIC . L AP ROVALS���
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
LM14 Notice (Perm)
COMMENTS:
NotiT
Document Cannot Be Duplicated
Date 5/3/96
No. 14433
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-311-001
Jurisdiction La Quinta
Owner Name Century Crowell Communities Permit #
No 45010 Street Bridgette Way
City La Quinta zip 92253
Tract # 25363-1
Type of Development
Comments
Lot # 1 .
Single Family Residence
Log #
Study Area 232
Square Footage 1654
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 1,654 or $ 2,844.88
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 Foothill Independent Bank/Century Crowell
ommum lesName on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Telephone 909-381-6007
Payment Received $2,844.88
Check No. 515344
Signature,n a� A QED PIA.A&Lnvn_
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