9602-156 (RPL)I
�►-."'�, ' LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
C
W'- Section 7000) of Division 3 of the Business and Professionals Code, and my
o :) M License is in full force and effect. -
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� LLI License # ub. Class Exp. Date
r; Date SignatureofContractor
„0) Z r -
r O OWNER -BUILDER DECLARATION
W;r I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
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I () I, 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
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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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
() I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. we:
Carrier wr..,.,. • •.r rr- Policy No.«„,.
(This section need'not a completed if the permit values s for $100.00 or less).
( ) 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 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.
(Owner/Agent) ' Date
ALC,I
BUILDING PERMIT
PERMIT.
�Jtstij- i..
DATE
VALUATION ���Rfy
LOT
TRACT
JOB SITE ADDRESS
79-295 CAlvliNO ANiAlt.EiLL0
APN
04-192-614
OWNER
CONTRACTOR
13
440281,11K fTORNI'm
n42195
I)ALM DE SEXr CA 92160
LA QUIM"A CA 922.53
(610),440.5521 C AL# 1104
DESIGNER/ENGINEER
USE OF PERMIT
`i )(PI, !tN (AGR SPA
FEE DESCRIPTION -I
FEES
J-.4
1� Ir AM�i0R SPA. 2."1.01,13
e
.' ESTIMATED COST OF CONSTRUCTION RUCTION
12,4)Sid .00
P CUM:.ff,C+''1j E StSAtN1ARY
PLA'1d Of ff?.CK' 'PS -I" 101-000-430-318 $93.60
CONSTR.I:TMONFEE 101 -WC -418-000 $'?44,0
iV11 C;HANICAL FEE— POOL 101-000-421-000 524.00
ELFCIMICAI, :F'TWI -- .POOL, 101-000-470-000 $4.3.00
PLUA413INC fi"F% -- POOL 101.-000-419-000 $27.00
SUB -TOTAL C0N'9rRVCT1'0N AND PLANCHEICK
$333.60
LESS .1?:RE-P.ATL? FEES
$6.00
MAIL, PERMIT Fro F,SS iJiJE, NO -*V ,,,, --r--
$333.60
RECD Ti
DATE" ; j5; BY
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
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 I
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain `
Bond Beam
Approval to Cover ILVJ
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:
Notice:
Document Cannot Be Duplicated
Date 12/22/95
No. 13984
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Homes Communities
APN #
Jurisdiction La Quinta
No. 79-295 Street Camino Amarillo
City La Quinta zip 92253
Tract #
Lot #
Type of Development Single Family Residence
Comments
604-192-014
Permit #
Log #
Study Area 233
Square Footage 2436
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 2,436 or $4,189.92
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 Tele*h 'e _619-360-7464
t
Name on the check '
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Ellen Patino
r
Signature k
T-
i•�
Payment Received $4,189:92 ` `
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
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