9512-094 (SFD)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 d License is In full force and effect. 314473 B 181806
r Cr r License # Lic. Class Exp. Date
rz r- Date Signatureof Contractor
p 6 OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
0_ following reason:
U) ( ) 1, as owner of the property, or my employees with wages as their sole
Z 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).
() .1 am exempt under Section B&P.C..for this reason
� Date Signature of Owner
04
0 rn WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
C) g Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
LO H � 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 U permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn Carrier Policy No.
? Z (This secticKfoe-d jati 0010ompleted if the permit valuati6AU forf$IQ0.00 or less).
r- o() I certify that in the performance of the work for which this permit is issued,
0 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 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.
Signature (Owner/Agent) Date -
ALC S
ate
A`cx
BUILDING PERMIT
PERMIT951.2-1i94
DATE 12/19/95
VALUATION . ,1 4J.if16 LOT 7y
TRACT 1_41
JOB SITE ADDRESS 79405 (,:AMINO i". C#RIL,LO
APN 664-192-017
OWNER
CONTRACTOR
CENIURY NOMES COMMUNMES
CEW i'RY HOMES CC?iblfi,ll,)•i MES
1535 S0T_rn4 D ST1t1rff €;200
1535 SOUI'H .0 S'1REET { 200
SAN 131:R1`iA1tDI[NO CA 92408
131:rRNAKOIN, CA 92408
f 0381-6007 C BL,# 2120
USAN
(909)391-6007
DESIGNER/ENGINEER
FRANK WNZA'LES cos ASSOC.
1334,117 AST CHAPi�lM
USE OF PERMi N(i 4 FAMILY.DW14A,LINU,
0CTF OA 4 AA6I7 4iSt AR79
72AN(:ii0 ocanuo ( I.A. QIi1N'P.A'NOWIS PWLSE 3C
l'.I,AN 3L XB '
FEE DESCRIPTION
FEES
IKAC'1'LMNSTRUC'f'Y N 29746,00 SE'
PO CIVPAT.IO 166.00 SF
GARAGEMAR'OR.T 506.00 b'F
F,STIRSATED COST OF CONSTRUCTION
1.61,259.80
PE- RN' T FFE SUMMARY
PLAN GREC'1C. FEE 101-000-439-318 5709.2!
CONST1 UC-FIONFEE 101-000-418-000 $356.50
M7E-CHANICAL rte:, 101-00042.1-000 $55.50
aFklRICAL FM 101-000-420-000 $169.73
i' XTrVMTNa.VEn 101-000-419-000 x162,00
SONG MOTION F'12 - RESID 1.00-000-241-000 $16.13
GRADING FEE 101-000-423000 $20.00
INFRASIWCTUREFFIE 22g-000-443-342 $3,578.07
ART IN PUBLIC PLACES - REvoi,C 701-000-259-000 $153.15
SUB -TOTAL, CONS`I RUC'IIO;N AND PLAN CHECK
$5,720.29
LESS RRE--PAID FF FS
D ^
TA L PERMIT PEU DUE NOW
$0.00
$5,720.29
JA N 0 8
1996
Fay
RECEIPT
DATE
BV
DA
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
'DATE
INSPECTOR
BUILDING
APPRO ALS
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.
1
Fans & Controls
Party Wall Insulation
,(,
Condensate Lines
Party Wall Firewall
Exterior Lath
.111
Drywall - Int. Lath
Final
Final
BLOCKWALL A OVALS
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
f
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
L
Appliances
Final
Final
Utility Notice (Gas) yl
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:
Notice:
Document Cannot Be Duplicated
Date 12/22/95
No. 13981
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-192-017 .
Jurisdiction La Quinta
Owner Name Century Homes Communities
No. 79-205 Street Camino Amarillo
Cit, La Quinta zip 92253
Tract #
Type of Development
Comments
Lot #
Single Family Residence
Permit #
Log #
Study Area 233
Square Footage 2746
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
in the amount of 1.72 X 2,746 or $ 4,723.12
Government Code 53080
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
r
Signature
ti.
Telephone 619-360-7464
Payment Received. $4;723 12
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