9510-064 (SFD)/h
LICENSED CONTRACTOR DECLARATION
N1 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
o O � License is In full force and effect. 314473 -.�'B—) VW96
r` W� ^-- License #i a �. Lic. Class Exp. Date ,•'' �-
,rZ r Date '� i Kjti Signatursof Contractor
Oma',, . -�P r .
ca rn OWNER-BUILDER�DECLARATION
J W I hereby affirm that I am exempttfrom the Contractors License Law for the
CL 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
Cl)
Date Signature of Owner
N
OU rn WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
C) Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo F< Q compensation, as provided for by Section 3700 of the ' Labor Code, for the
X W LL performance of the work for which this permit is issued.
0 J J ( ) I 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 L) permit is issued. My workers' compensation insurance carrier & policy no. are:
CL LO rn H Carrier Policy No.
adZ (This sec4idi�.&IF�e'"ch`n-& beiaompleted if the permit valuatioUll'918P4100.00 or less).
o
C)() I certify that in the performance of the work for which this permit is issued,
O I shall not employ any person in any manner so as to become -subject to the
g 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, indemnity
& 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 voidif
work is not commenced within 180 days from date of issuance of surd
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 informa??jon in
correct. I agree to comply with all City, and Siete laws relating to the boilding
construction, and hereby authorize representatives of this City to enter upoi the
• above-mentioned property for, inspectionses�,.�LC133�1/_
Signature (Owner/Agerit)
Dats f G °fir
�. `:- •-.
A"'
BU:LLDING PERMIT
PERMIT14
0-06
DATE ''�� �`" ''
VALUATION "p'�"'!" ' "
LOT '
TRACT
JOB SITE ADDRESS 79-275 CAMING ML 070
APN 604-192-0261
OWNER
CONTRACTOR
CENTURY `ROM S C044MIJNi't E -S
C'4:�: ,'URY T10AI::114 COi 41MU:�IP E, S
15.151'01(Jr T. -T C SUR LIT x#200
79-275 C."A R40 OIL ORO
SAN .B1~:RNAR.I3INO CA 92409
SA=N BF _ii:NARDIN, . CA 92408
(909)'381-09)7 CUL# 21.20
r!►il. r�t}�
DESIGNI.ERiENG (NEER iQq
1336 E.AS'i' CHAPIWAN A VOIRU'F'
USE OF PERMIT?J""'O 'E va a LA.esvIJ
ORANGE, CA 93666 (909)532-6878
kA.NC'HO UCU VIL# U ;O LA QW KII'A N WI'E
4':FiAM.. 318 PL AN III
FEE DESCRIPTION
FEES
TRAC1' C.`(3NS`i'Ki1C:°1'I0,'V 2,2160) SF
P0RC1•UPAT10 168,00 SF
GAIIAOMARPORT $06.06 8F
ESTItATU i ED COS.s. OF CONST.IY$7C'IiON
132,480.80
I''iiltMI'T IF EE SUMMAI V
Pf,AN c•''tlECK, FFF,, H)!-00041()-318 -000..439-318 VI M.50
CO4NS'TRUC I"1t;aNl FRE 101-000-418-000 $155.00
MECHANICAL FEE, .101-000-421-000 $53.m
O.W1'iz1.CAL FM 101-000-420,0100 $151.18
PJAT-NI' WO FFF )t)1_(lt)f1-41.y-i0p $144.00
TrONG NKY110N FES - WE SID 100-000.2-11-000 S13.25
GRAsDIN13 FEE 101.000-423-006 340.00
INF'RASIRUCTURE FlYM 225-0()0-443>342 $.4930.54
ART 707-)0(1-255-000
r,
„,
SU13-'VO'V'A. CON�s"�MUC"TIONAND PLAN C.11Ef;'(ti
$4,778.17
LESS PRE-PIUD FUS
rsr� j
O TAi, PERMIT FEES DUE NOW
$0.00
$4,779.17
4 1995 F ERS
4,77W
RECEIPT
DATE
BY
DATE FINALED-
INSPECTOR
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
LP r
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.L
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. 113791 Permit #
Log
Owner Name Century Homes
No.
eet
City La Quinta' Zip 92253 Study Area 233
APN # 604-192-026 Tract # 124517 Lot # 0 Square Footage 12216
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 of 1.72 X 2 216 or $ 3,811.52 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.
Fees Paid By Century Homes Telepfr6i`e?.9Oy-381-6007
Name on the check
By Dolores A. Ballesteros f ;
Superintendent
� 4
Fee collected /exempted by Pauline Pearson
PL-9
Payment Received ..Signature PA, , l X.1 AA o Rk a w AA-, $3,811.52 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