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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
Date `!. ;r�J f 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 coristruct `the project (Sec. 7044, Business & Professionals
Code). y
() 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 Ziis"�il'I7:> W""'. CO. Policy No. M� 901
(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,agfiiPthat if I should become
subject to the wor ers' compensation provisions,of Section 3700 of -the Labor
Code, I,s�hall forth�gijh comply with those provisions, �+' � .
Warning: Failure to secure Workers' Compensation -coverage -is unlawful and
shall subject an employer to criminal penalties and cwil`fj s up to.$100,000, in
addition to the cost of compensation, damages,a 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 11 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 in inspiktion,,purpose.s.
Signature (Owner/Agent') !"
BUILDING PERMIT PERMIT# _ °°NTR°`#
1af;416-132iii 3534
DATE VALUATION ,71�♦ LOT t TRACT
IT
APN
ADDRESS 45-220 BRIDG;�17R t�'AY
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY, ciwiw,L1. C:moxtu-.,grr►E
CB.-' %vf i;I i.C7`J1M(.i~ CO, tTl�lI`T 1 F s
153: SO. "1 " S i' U_rr, !C'I`E. ax)
1335 SCJ. "D" EUREFT, S -M. #200
`AN BERNARDIN, CA 92409
SAN BERAiARDINO CA 9240:4
{909)'t9I-W
0:W)381-6007 CW 2120
USE OF PERMIT
FsCN1AIVTIIV ACiL°ILAR ASSOC.
SiNOUFANULY DM.-IL1NG
pasty PAsSER0 AVE.
RWFRSH)F� CA M05 .✓ -
I)EL R1 Y trn r A Q9JTNTA NORTE
PILAN
TRAt;I CONSTRUCTION f,461.(* SI:
>
POR+ IVI?ATIO 36.00 3F
-GA'RAMICARPORT 413.(;x0 4f
ES'ITNIA'I',ED COST OF C.MNS'I'.RUCTION
PERIM"' FE11? SUMMARY
:E%A:N CNEX,R IMP 101.-000~439-319
C:ON31"RUCTI('x4 t't~;f 101-000-419-000
N111C ANICA1: YM 101 -000 -421 -OW S47.00
ELEC'�i'R1C:,�., t�,sr? - 1U1-00t?-424-tK30 s'l4�.t�►
!'1.l11 OTNC F 9F 101-000-410-000
STONG IMOTION FEE - M-SLO 101.000-241-000 ".79
GRAVIN(:t Will 101-000-4'Z3 (M 5211.00
1NFRASTRtlUfl1JRR FbE 2254M44-1-342 $1.9677 1
_SUB- OTA1-C;.(�Ai�(?,UCTION AND P`1c,.�1,.N C�;}"�iECK
03141.x16
�+�
0.�ESS, 1�J<.I.iTA1D FFr—S
- aOTAI,, PERMIT FEES LIVE NOW
$3,341,16
RECEIPT
DATE
BY
DATE INALED
INSPECTOR
'INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVAL
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 L
POOLS - SPAS
BLOCKWALL PP OVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Z.
Final
COMMENTS:
Final
Utility Notice (Gas) 44 7
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 00 oeo
Utility Notice (Perm)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/19/96
No 14603
Owner Name Century Crowell Communities
No. 45220
City La Quinta
Tract # 25363-1
Type of Development
Comments
By
Street Bridgette Way
Lot # 13
Single Family Residence
APN # 604-342-006
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area 230
Square Footage 1461
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 1.84 x 1,461 or $ 2,688.24
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/Topaz 'Telephone 360-7464
Name on the check
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $2,688.24
Check No. 28118
Signature , , � 0A,4_0 lJ 1 ffiAAJ%16_1)_
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