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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
5_%2z6 (253 212297
Date , C� Signature of Contractor t .1
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.
STATE FUZZ'vi3 1l Iiii'i�-moi
(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 Californi and agree that if I should become
subject to the workers' compensation r visions of Section 3700 of the Labor
`Code, I shaII fo h Rh comply with tho a ovisions.
Date: 3 101 7 Applicant b -r_ L
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 propertyjor inspection purposes.
Signature (Owner/Agent) - t'� Date I
a
BUILDING PERMIT PERMIT# CONTROL#
8741.1.4131 4789
DATE 3110/97 VALUATION i1 ,gtl{f oo LOT TRACT
JOB SITE
ADDRESS 4-9-04013MIX.��;'I"IE WAY
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LY;'4P1 l t.1'iJ;':
:;IJNfi1SE !'Cl(lI.K`;
45.040 ksk1l..t 3t:, ITF. WAY
44028 ELK.H0RN'IX.
I.A QIJIMI'A `'A 922,:3
PALI\4 1)F.Stwr ('A 922n0
000.040-5521 C't21.,# 1604
USE OF PERMIT
t1N1) OR .311A 13,%XJ.M 4,S
EINTINNIATE'D c`.ci` T 03V c,ONS RUCTION
� ..• .
1'i+,RR11 f' �� M;1: ,'ill4il+►+tA1i1'
�...
PLAN 0 [#%.t'i: k t:ti 101-000-4;9-;l8 X9!1.45
r:'+*Ni'iti?i,fC"iic�1`41%►:►% 101-(if,K?-dlft-(1iN1 S►Slilfr
NIEVItANiCA.L170-.Ilf)01. 101-000-421.000 s M
i,:l.,►.zC`C#tt�:,'�t, i,6i: -- f.h:plJL l01-fli,�i-�1fi-Cx30 &�5.�2
PL1*J. HW1r l i i--11+---su►t. 101.-000-419-000 S'i7.t �
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1"IJIVRY1*A1, CON- Si'RIJ(MON AND PLAN C 11F11 K
�1.tii a5
LESS PRE -f'i't D 171'ES,
$000,
TOTAL 1"EEMIT FERS DIN NOW
S;>U.45
RECEIPT
DATE
BYDA�
E
INSPECTOR
o�
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
Compressor
Insulation
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 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
Final
Utility Notice (Perm)
Noti:
Document Cannot Be Duplicated
Date 5/3/96
No. 14435
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
_`
APN # 604-311-004
Jurisdiction La Quinta
Owner Name Century Crowell Communities
No. 45040 Street Bridgette Way
City La Quinta zip 92253
Tract # 25363-1
Type of Development
Comments
Lot # 4
Single Family Residence
Permit #
Log #
Study Area 232
Square Footage 1469
Check was short by $12.04 w c *was paid in cash y Dan Cleaves.
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 1,469 or $2,526.68
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 <Telephoiie 909-381-6007
ommum ies �� .. ., • .
By Dolores A. Ballesteros t w
Superintendent ^
Fee collected /exempted by Pauline Pearson Payment Received $2,526.68
Check No. 515344/cash
Signature 22AiAX)Z,,�
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
F
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting