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LICENSED CONTRACTOR DECLARATION
r 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
7111 KR 1.013119q
Dat Signature of Contrac"'tor"
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 isnot 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.
(x`) 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 y i CO.Policy No. q
t IU Y1y T *41 S, O
(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 workers' compens�I' —pro eons of. Section 3700 of the Labor
Code, all ort Lvith-comply w,iib thos provlsioi
!Date: � ! Applicaht rte'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, i6
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 acid 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 ins
pectio +purposes. Y
/Signature (Owner/Agent)1 �j Date
i
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION M 16,767LOT TRACT 3,029
JOB SITE ' APN
ADDRESS 4.9-034) 8KIDG1JTT'E WAY 04-311-010
OWNER CONTRACTOR / DESIGNER / ENGINEER
ris?`ii"(IRS'C)if)WELLC 0,40MMMES CENIURY C°f:C)WTiA., COM;4'iONITIES
t535 SO. "U. sI'RI-an" 1f200 )`3S�(). "Il" tiCki?t:!',5[�. #TUU
SAN RERNA[tt INO CA 9111)9 SAN liEKNAR1_7INO (,'A 92151>5i
Oi)r)):ih 1.6017 C[13..ff ".1120
USE OF PERMIT
$; D
8F0 - DEL R:EY 1.0T 3. P[.r :+1\7B
1°RAM, CONS111RUC1170N 2,010,04 811
t1A <AGEiCA)2.x'ORT - 3i9X$IJ S11
.Stli?t-'jYI'i�1,i.'�Jivi�tiJC:'i'l.(>++! xiUDi+i.�441C,:i1_x?i
J�J
1.23 X998
'I'll, If'R I T' F I: S �i1i f, NOW
r -
IiRECEIPT ( DATE (I I DAT FIMD/ w ( INSPECTOR
-,".Ji 169
$000
.l'el Y•A,kA'18N. A All tl~ll.:iR A M�•A.M1.,/IY 7'3.3 �,.-Y.i�il �r
PERMIT FEE, SUNINIARY
i.`ONS'1'Itt;tr3' ON FEE
101-000-4)9-O00
3699.00
PLAW C"riCIC FIT-
10 ! _W, -431).3 i R
SSKfi . 4 �t
AT}ICHANICA1 11, .r,
$47,00
411 1A; : ik ICAL IT, 1
10) •Cit)()- �ti-tif)ll
51: 6.ti
iI'LI4101NO FEE,
�` 1.41-000-419-OOi1
317.00
'itt)NG NI(XfT )N l l:: - R:1?.S[1;= 101 -0W -2414)n)
l t to
ti;R VXNOtL9
101-00[-4234;11f)
'40.i1ti
NFWTKUC URi1 FU,
250 0-stu3- 42
$2,627.7
AR77 I N KWALIC P1.ACE'S - Rt:S1D 711 -000 -x,55 -Wil
5.11.yZ
.Stli?t-'jYI'i�1,i.'�Jivi�tiJC:'i'l.(>++! xiUDi+i.�441C,:i1_x?i
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1.23 X998
'I'll, If'R I T' F I: S �i1i f, NOW
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IiRECEIPT ( DATE (I I DAT FIMD/ w ( INSPECTOR
-,".Ji 169
$000
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
Z — Z 2-4 k,
Compressor
Insulation
/2 —,Z4 — QE
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
3�J%F
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 Test
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:
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
I�
Final
Utility Notice (Perm)
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 7/22/98
No. 17380
Owner NameCentury Crowell Communities
No. 45-030 Street Bridgette Way
City La Quinta
Tract #
Type of Development
Comments
Lot #
APN # 604-311-010
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Square Footage 2,010
Single Family Residence No. of Units 1
At the present time, the Desert Sands Unified School District does not collect fee's 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
1.93 X 2,010 or $ 3,879.30 the property listed above ania that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid By CC/Foothill Independent Bank/Ed Knight nelephone 909-381-6:007
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by
Signature az
Juanita Green Payment Received
Check No. 604540
$3,879.30
NOTICE: Pursuant of Ass ly 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
above will begin to run fro a 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
collect 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