9512-031 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is in full force and effect. 31,14 15 1/961
License # Lic. C ass Exp. Date
Date Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure isnot 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
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. are:
Carrier Policy No.
(This section need not be4cfompleted if the permit valuation , �yrA100.00 or less)..
O
IC t�►a in the performance of the work for which Phis 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.l 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
rof 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
ALCM
BUILDING PERMIT
PERMIT�y1��'
DATE IV 7i9J
VALUATION S161,92S.&
LOT 49 TRACT 24517
JOB SITE ADDRESS
APN
79L-3511 CAI1 CAENO AMARILLO
604-192A23
OWNER
CONTRACTOR
CENTURY HOMES COMMiINFrIES
CENTGrRY Hows cbmmi1N1 m -s
1535 SOUI'11 O SIREET #200
153.5 SOUM D MEET 9.200
SAN IIMARUINO CA 92405
SAN BER,NAWDIN CA. 92408
(90)381�007 CELL# 2120
DESIGNER/ENGINEER
(9()4)x}1..({{)()'7
MW R W t10NGALB & P.SSOC,
1.336 EAST C 1;APIMAN Ai+TNUE
,.f
�.i
USE OF PERMI'324G ,.E FAMILY DIAMLLING
'e . et m—m7;
RANCHO 0Cf a t`1i:1 0 (lt LA QUfNTA'i<tt7k2.'1'E Pil 3C
PLAN 40AP. �
FEE DESCRIPTION
FEES
` RfWT CONSIVUXT1014 3,728,00 :3F
POtCW/PA.TIO 168.00 SF
GMA00CA12.POR:,f 590.00 SP
�',.S'TTNIA`i'ED COST O.6' CONSTRUCTION
PERMI >C `,.EE SUMMARY
:PL.A1-1 CITECK FES 1014= 439-318 5710.85
CONS'TRUC-TION FEE 101 -000 -4th 00 $856.50
WCHANWAL FEE 101-0L*421400 $49.00
FLEC" 1`1d1.CAL F'EE 101-000-420-000 $170.78
>=):f 1i3)A1CF:P1sE ).01-000-419-000 $174.00
STONG ItMar[O +i IMS-'R;ES1U 100-000-241-000 $16.1.9
t3•t:CA1al:N(.,.FEE 101-000-4123-000 $20.00
!Nt 1� AS'.i`13UG" 1`f 1FtT 1`11- i 225 -MO -413-342 $3,5V3,12
ART 1$E'afr 191-fNif)-2.55-000 SISI} R?_.
,SU1340TAL CONST7S..1 CTIOd`1 AND P.L.AiY C1113CK
$5,74,5.A6
w LESS PRE -PAID FEES
$0.00
------------
,00 �A TOTAL PElil� IT FEES DUE NOW
D
$2474526
JAN 0 8'1996
DATE
BY
DA
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPR VALS
MECHANICAL APPROVALS
Set Backs j
A
Underground Ducts
Forms & Footings
Ducts
Slab Grade
0
Return Air
Steel
Combustion Air
Roof Deck
Q
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
r 10
Final
Final
POOLS - SPAS
BLOCKWALL
P OVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
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
7W flEquipment
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer LateralPool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
'Z
Appliances
Final
COMMENTS:
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)
Notice:
Document Cannot Be Duplicated
Date 12/22/95
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-192-023
No. 13975 Jurisdiction La Quinta
Owner Name Century Homes Communities Permit #
No. 79-350 Street Camino Amarillo
Cit, La Quinta zip 92253
Tract #
Type of Development
Comments
Lot #
Single Family Residence
Log #
Study Area 233
Square Footage 2728
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 2,728 or $ 4,692.16
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.
, ,:" ; r, .
Fees Paid By Century Homes/Community Bank
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Ellen Patino
Signature
r Y
Telephone 619-360-7464
t
i,
Payment Received $4,692.16
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