9510-063 (SFD)LICENSED CONTRACTOR DECLARATION
NI hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W Section 7000) of Division 3 of the Business and Professionals Code, and my
i o O � License is in full force and effect, 314473 B ,,f 1/31/96
W License # 1 Lic. Class i ----Exp. Date
n ` Date M Z- e-"4 SignatureofContractor'`i'�
Z
0 0> OWNER -BUILDER DECLARATION -�
J W I hereby affirm that I am exempt from the Contractors License Law for the
following reason:
Z( ) 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
N
OU rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
C) 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo r gO compensation, as provided for by Section 3700 of the Labor Code, for the
X W W performance of the work for which this permit is issued.
O J Q () 1 have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
p U permit is issued. My workers' compensation insurance carrier & policy no. are:
a rn H Carrier Policy No.
qT z (This sectioflneedopt i ei ompleted if the permit valuation, 4v fgr2$1,OD.00.or less).
r- C) () 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 Section 3700 of the Labor
Code, I shall forthwith comply with those provisions,
Date: Applicant
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 andtate sthat the above inform oni
' correct. I agree to comply with all�City, and,State laws relating to the build gy
construction, and hereby authorize representatives of this City to enter upon the
i • above-mentioned property�yor inspection purposes"-
`
ignature (Owner/Agent), __.-------'--DaEa
ALC0
BUILDING PERMIT
PERM"91.510.00
DATE 111110117-.t
VALUATION &31 0, .3J i LOT TRACT Z-1.1) i Y
JOB SITE ADDRESS 79-245 CtiMINO DU 011111
APN 604-1924 27
7
OWNER
CONTRACTOR
CPNIURY MON14FS COMMI.T1`7YTIES
CENTURY HOMES COMMUNl'T,' ES
15:15 SOU rF.,D S111it.' Ref # 240 -
79-245 CAM NO DEL ORO
SAN MNARD CA 92408
SAN '81', $NAR1]IN CA 92408
(909)3131-6W7 G:Wt 2120
(4()9151-t�4A7
DESIGNER/ENGINEER
USE OF PERMIT;� j<evLt .i' t1i1'111 d WSW clk,1lY41
KAN040OC:07'11J.0t LAQUI.N'1'AN018't'F
PHASE M FLAN ZK
FEE DESCRIPTION
FEES
'1'1P NCT C0N3'1'RUC;'rI0N 1,907.IRI V
PARC"A I0 168.00 SF
GARAGEICAltPOR 1 528.00 3F
1!',.�'i(-isi'.l XFE1)1; OST Or CdPJSIFRUC ION
116,133.30
PERMIT FEE SU.I!?M.!13iRY
P11 -AN C REC, K IRV-.b' 10]1-0114 9-31R $5$1.85
CONST' UC"r10N 1'Ll-s 101-00"1.8-000 5699.00
A;1ECKA ICtAL fla. .101 -000 -421 -WO $55,50
ELECTRICAL FM 101-040-420-000 5140.74
PJAMfRIW0 FIS 101-M0•4.19-0011) S 144.00
ITONGN40TIONF13ZE-RMID 110000.241-000 X1.1.6.1
OIR ADINO FSE 141-000-423-000 $24,00
INFRASTRUCTURE FEE 225-U00-443�-M2 $2,562,73
ART rN pT)R►,1C 11r AC4iS . err, 71111 -WO -251-0m, 540,3'
., UB.t , ilii.. CVNiMUC'TF,ON t1.,�'iD PLP -.1, CHEICd,%.
LESS PRF -PAH) FEES
$11,00
ft
oCT� O TOTAL PERKI,FEES 11t1K1~`OW
$4,258.76
g
�99S TMAT, PRW (.cT 1TR FRIG, 8
RECEIPT
BY
DA ALED
INSPECTOR
yUATE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/
Ducts
Slab Grade
Return 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
BLOCKWALL APPROVALS
POOLS - SPAS
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
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)
COMMENTS:
DESERT SANDS UNIFIED SCHOOL DISTRICT
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
Date 110/23/951 Type of Permit I La Quinta
No. 113790 1 Permit #
Log
Owner Name Century Homes
No. 79245` Stmreet tCamino~Del-Oro _
City La Quintsip 92253` - +Study Area 233
APN # 604-192-027 Tract # 124517 Lot # 0 Square Footage 11905
Type of Development Single Family Residence No. of units
Comments
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 o61_._7_2_x 1905 or $ 3,276.60 have been paid to D.S.U.S.D. for
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.
4 `
Fees Paid By Century Homes TOu� et'!99
-li9-381-6007
Name on the check _ •�?'.
4
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson L _
Payment Received
Signature Si' 1 A Al -91 I. „ Pj A 6A/k $3,276.60 Check No. 101138
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