9510-066 (SFD)r
LICENSED'CONTRACTOR DECLARATION
N 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
oo O License is in full force and effect. +1.1473 rK13_ 1i31I36
r WW n License # 1 Lic. Class' Exp. Date
N r• Date 14:1 j `K' Signatureof Contracttor , - - • -:.- ---..•T c" "4
CD H o> OWNER -BUILDER DECLARATION—,
LLI IU G I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
I.- 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
LO
Date Signature of Owner
N
9O rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
o g Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
LO H IO 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.
p 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 U permit is issued. My workers' compensation insurance carrier & policy no. are:
4 Lo rn F Carrier Policy No.
qT ? (This sectforbneeckn 5t I eldompleted if the permit valuatioNis fcrd$100.00 or less).
co
N cy() 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, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees. f
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
1 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 buiidi'ng
construction, and hereby authorize rr presentatives of this City to.enter upon the
• above-mentioned property Tor I inspection purpose
Sig
nature (Owner/Agent) _....er• =_; ` _
. 1.
A"'
BUILDING PERMIT
PERMIT�i���-f�6
DATE
r91'lf1 "-
VALUATION
LOT
4A TRACT ZNF, L d
JOB SITE ADDRESS 779-3-35, CAfL9111KO DEL ORO
APN 604-1192.024
OWNER
CONTRACTOR
CF-,*NM>RV H0MF.%C.OMMrNMRS
CS:-NTUR'Y. TIOWS COWN!".
.1535 SOLT111 D =BF T #200
71-335 CA iNO DE1, ORO
SAN CA 924011
S.AN BE NARDIN, CA. 92408
(90)3131-11007 CBL# 2120
-tS(in7
DESIGNEMNGINEER
:FIRAW C0N7MYS eft A=CfATE
la3G3yNaI iFi?iVlAP:I dpi"v 1`1`1
USE OFPERWTiAA: QTA,. ,J'J V Y .J4'1:L.1..1V� t
C.ul AN��R. CA 926166 (01}91532-6978
RANGli0 OC:O'.I'ILIA) C� LA QUJN'1'A Nt)tt'1'E
PIUSE M .K.AN 4 A
FEE DESCRIPTION
FEES
P
PJ
Cr3;+:STRUCTION
ELEt
'pI
S"
t3)''
1WRASTRUC'rUKF,FEE
O/ ' �`
V e
'MACT CONS'1'.ttUCi'.IUN
PORCWPAx'f0
OARAOF)CARPORT
F.�S'iC1t AT1,,,D COST OF
E.RMITF Fri. SUMMARY
-AW C,'fT. CK FRE
Me,. 101-000-418-000
WICHIOUNI :A, FIFIE M-000-421.000
I?JCAL ME 101-000-420-000
.tT143M101. FE lot -000 -419 -OW
ONG MO IONI FlEE - RESM 100.000-241-000
MANG FU 101-000-423-000
225-000-443142
ART 1N 1aUM..f-C t'T,A(:T,d - RF—ST11 701-000-251-000
aid TOTAL CONTSM. UC 1,10N AND
O .fO E.A_'L .PE,R1%1.JT
z4 1995 q:O,.+,.N1011ri
2,43100 :3P
.168.00 SF
590.00 S:t^
CONS'"1'RUC TIO11
$66415
$304.00
1y.t10
V60-56
S!,%.110
$14,61.
$3,236.37
P±i.AN CHECIX
LESS PRE -PIVD FEES
�i�'MS DUR ASE.PTr
,: El RM p.F,ES
1,46,073.:20
$5,21.4.47
$0.00
S� ,2114.47
5,214.47
RECEIPT
-DATE
BY
DATE RNALEO
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
- DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS .
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 1A 7
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 I I
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 Z'
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. 113793 Permit #
Log
Owner Name Century Homes
No. 79335-- 'Stree_ t Camino Del Oro
City La Quinta Zip 92253 Study Area 233
APN # 604-192-004 Tract # 124517 Lot # 0 Square Footage 12436
Type of Development Single Family Residence I No. of units 0
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 2 436 or $ 4,189.92 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 Telegi_hone 909-381-6007
Name on the check
By Dolores A. Ballesteros
Superintendent _
Fee collected /exempted by Pauline Pearson
Payment Received
Signature$4,189.92 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