9512-098 (SFD)u) LICENSED CONTRACTOR DECLARATION
a1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the B,us' , ess and Professionals Code, aid my
C co J1 W3 Di V.) 10
License is in toll force and effect.
ri WLicense # Lic. Class Exp. Date
rZ n Date Signatureof Contractor
c'o 0t`
0> OWNER -BUILDER DECLARATION
J U C I hereby affirm that I am exempt from the Contractor's License Law for the
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
LO Date Signature of Owner
N
Orn
U WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
o Z () I have and will maintain a certificate of consent to self -insure for workers'
LO < Cc compensation, as provided for by Section 3700 of the labor Code, for the
F.ZX 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
p Q permit is issued. My workers' compensation insurance carrier & policy no. are:
a LO Carrier _ Policy No. _
? (This section nee ri t' a completed if the permit valuation is or $� 00 or less).
OD a () 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
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.
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) Data
ALCM
DING PER.,
�x JUI 93StM1T?i;1�,'2r♦ij
DATE
VALUATION
TRACT ;
JOB SITE ADDRESS i 1 EkliX :�;A:,V1=A:JKJUAPN
14- Jd IAI.t
OWNER
CONTRALTO.
C E TURY HOMES CO MNI. t7.ES
CI:::i`d'1`U7 Y HOMES i„ ODS MUNrIlES
1.535,9- 0Vr1-I U 5311CIR ' 4200
1535 SOU fff D3 STREET -1#200
SAN RER.N.A.,1 3INO CA 92408
SAN B RNA.RDIN CA 92408
(909)381-6007 GK# 2120
f3ID4)3f{ 1-hilii7
DESIGN[iYGINERil,}`�5 c, AOCIA"
''T 2 ,.Y E, ii .f Nr \ Ai("
I3s6 EE�.aI GfI.APMAN
OII`tWCLy CA 92666 ('714)532-6878
USE OF PERMIT
PLAN IXBR
t•
FEE DESCRIPTION
FEES
TLRACT CONSTRUCTION 1.804.003F
,K)RCIi/PA,TICy 168.00 :SIF
GAR.AGOCARPORT 507.04 SF
ESTIMATED COST OF CONSTRUCT ION .
110,128.80
DP!ERMITFEY,.SUMMARY
PLAN CIECK MT 101.000-439.3,N $575.48
<:ONSTRU•CrION3M 9 101-000-418-000 $685.00 '
MECHANICAL FH 101-000-421-000 $61110
Fx.EMICAI. I,EE 101-000-420.008 SI.X78
P:GLhNISING FRIZ 101 -WO -40-000 $144.00
TONG MOTION FEL - RESID 14()`.000-2241.000 $11.01
GRANNG FU 1,014)00 -423 -WO $24.00
1NFMMTRU(,'TURE nE 225-000-443-342 $2,427.62.
Alt's.' IN Pi. BLIC PLACES - RESIC 701-000-255-000 $15.32
SUB -TOTAL CONSMUCnON AND PLAN CHECK
$4,N37.21
LESS PRE-PA10 FES
$0.00
.A.L I';E.DlZ IXT JF':CCS D!ild E NOVV
$41987.21
FJfAN 8 1996
; .
RECEIPT
DATE ^
BV
DA NA D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPR VALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade f X4
Return Air
Steel rl i_
Roof Deck
Combustion Air
Exhaust Fans
O.K. to Wrap
F.A.U.
FramingA%A
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation 7/ ?i0
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL AtIhOVALS
POOLS - SPAS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 1111Y6
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:
+
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date
No.
12/22/95
1J-1U✓
Owner Name Century Homes Communities
No. 79-325
City La Quinta
Tract #
Street Camino Amarillo
Lot #
Type of Development Single Family Residence
Comments
APN # 604-192-013
Jurisdiction La Quints
zip 92253
Permit #
Log #
Study Area 233
Square Footage 1804
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 1,804 or $3,102.88
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
Telephone 619-360-7464
Payment Received $3,102.88
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