9512-033 (SFD)u) LICENSED CONTRACTOR DECLARATION
N U) I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Bus•r�ess and P ofessionals Code, and my
O Lo License is in full force and effect. 31 `i/3 1/31/96
r- WW License #_ Lic. Class Exp. Date
Z Date Signatureof Contractor
(D H o> OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's 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).
( ) 1, 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
Orn
U WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
o 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo HO 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.
O 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
pU permit is issued. My workers' compensation insurance carrier & policy no. are:
rn F Carrier Policy No.
v z (This sectio" A ' Hli8 el mpleted if the permit valuatio is'0r'$ 6 .00 or less).
00 Z)() I certify that in the performance of the work for which this permit is issued,
Cy
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
c 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 1 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 property for inspection purposes'.
i Signature (Owner/Agent) Date—
ALC 0
ate
A""
13 ALDING''PE-RMIT
P R T :�l��-fid
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DATE
VALUATION LOT
TRACT
JOB SITE ADDRESS %977 i.t\M N ,j•,,
APN 604-192-074T
OWNER
CONTrOR
T
1 Syf !'Vii tj iQ��;s Ci��' �('(
Wrn'URY HOMES C()Mi4 UNC! ES
1535 S01fl H t) SI'RE17 62()0
1535 SOUTH D STREET x,'100
SAN BCRNAI2DWO CA 92408
SAN BF INARDIR, CA 92408
(909)3816007 C.k3.119 21.20
(909)3$1 •Cr007
DESIGgfjfj ENC�INE
Ec� p A
.1aHI ;51' __
c+rwirr n.tA.r♦rw�rr zvwrr
11,36XASTCHAPMANAVE.
ORANGi0 CA 92666 (714):532-W78
USE OF PERMIT r• • •
XPLNC:HO UIC:O'.CILLC) (WLA t�1l1N•I A NU (113 ' 3r.:'
PLAX � CRX
FEE DESCRIPTION
FEES
TRACT CONSTRUCTION 1,907.170 S1~
P0;RdV.PA':f 0. 168.00 SF.
GARAOE/C.AR a011T 528,00 3
0STUNIAT.1 D COST OF CONSTRUCTION
11.+5,133.10
PERMIT F:1a"E SiJi1TT0'SNRY
PLAN (JW.CK FIG $5M.£15
IC"ONST12i3CTI 14I FUS 101-000418-000 $699.00
A&'C• ANICAi F&I 101-000-421-000 555.:50
ELIX"nIICAr IME 101.000-420.000 $140.14
kl.tiMBINCa FEIi 101-400-419-000 $144.00
I'G3•hiRiG MOTION FIM3 RESID 100-000-241-000 $11.611
GRADING )INl1 FMM 101.-000-423-000 $20.00
1NFRASTRUC!'LIRE FE 225-000-44"3.342 $2,M2.73
Afirr 1Ti Pt✓Tvc,, P1,A.CGS - RE -sic 7I31-wo-2 S5-000
SUBy7"C71`AL CONSTRUCTION ,AND PLAN CHECK.
$4,7.5$.76
LESS PXV-PAID f FBS
$0.00
�.
Ni�W
°I' L 1P>�i�A�'r FE DUE O
D
$4,258.76
� ,
JAN 0 8 1996
RECEIPT
DATE
BY i'"
DAT L 4
INSPECTOR
t
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 Q
Exhaust Fans
0. K. to Wrap 7F.A.U.
Framing
Compressor
Insulation
Vents ^
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation (o
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Finalfa*kvPOOLS
- SPAS
BLOC ALL 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 42Heater
Final
Water Piping I
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Server Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping Pl_ 144a
Gas Test 1
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL OVALS
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)
`I V
Notice:
Document Cannot Be Duplicated
Date 12/22/95
No. 13980
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Homes Communities
No. 79-200
city La Quinta
Tract #
Street Camino Amarillo
Lot #
Type of Development Single Family Residence
Comments
Jurisdiction
zip 92253
APN # 604-192-018
La Quinta
Permit #
Log #
Study Area 233
Square Footage 1907
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 1,907 or $3,280.04
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
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Ellen Patino
Signature ci
Teiephone 619-360-7464
r�
Payment Receiv(;d $3,,2$004
Check No. 0924
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
.. Z, _",w("::.�.. •..vey,�:4",+.v`�fVS'! �.r':::....y,y.�„"`t"-rpt a..a�••::t::t, :7i'w��'�injxAri`'+i"L�i„�ar�I �i•+r7Y'^••�.,..r..,-�..�,a .c. iti+-."'`ri •.. q.+v'.- .v= air- �_ -- --- .'
OWNER / BUILDER. INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
fiom the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades'that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you-emplov;or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insumpce, disability insurance costs and unemployment compensation contributions.
__ r
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's cl:')mpensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.q. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structute is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is 'providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-105 Calle Estado
La Quinta,. CA 92253
(619)564-2246
FAX: '(619) 564-5617
OWNER'S SIGNATURE/DATE
`1 —?�e� A o�-� �. �.e� A VVIAct c.L�
PROPERTY ADDRESS
7p 7r'
PERMIT NUMBER(s)