9512-035 (SFD)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 Business and Professionals Code, and my
O co License is in full force and effect. 31,4413 B 1/31196
N �W License # Lic. Class Exp. Date
r.Z r Date Signatureof Contractor
(0 F OWNER -BUILDER DECLARATION
J W 1 hereby affirm that 1 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).
( ) 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
C0 Date Signature of Owner
N
OU rn WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
C) 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
HMO 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.
Q 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 0) Carrier Policy No.
IT _Z (This secf166'MWnVt•9eompleted if the permit valuatio " is f6W60.00 or less).
n Cy () 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.
Signature (Owner/Agent) Date
ALc0
BUILDING, PERMIT
PERM IT4.5i2}.S
DATE . r-
VALUATIONST .7.f..11I LOT
TRACT > 4
JOB SITE ADDRESS 79-355 CAM.I NO AMA[UI,IA
APN 604-192-012
OWNER
CONTRACTOR
CENTURY1-1OMES COMN'ILMMES
CENTURY HOMES COMMUN.1'i' ES
1535 SOU' H D S'1`R;1;ffr if2()0
1535 SO(1' H D S`1'REET #300
SAN AERNARDI' O CA 92405
SAN $ERNAR.DIN, CA 92408
(909)38t -6W7 CBL# 2120
(909)3RI-6007
DESIGNERIENGINEER
F"NK GONZA1,E3 & A*980C.
- - '%J
1336 .EAST CH AVE.
NA
USE OF PERMIri l�Il. ra .r ►;v. 1
ORANCi - CA, 9%66 (714)532-6878
RANCHO OCOTILLO @ LA QUiWANOR7E,
PLAN 2AkX
FEE DESCRIPTION
FEES
TRACT CONSTRUCTION 1.907.00 yF
PORG"I1/AATIO - 168.00 SF
GARAGE/CARPORT 528,00 SF
ESTIMATED COST OF CONSTRUCTION
196,133.10
PIDRIAUT FUM, SUMMARY
PLAN CRECK FEE 101 -W-439-318 $584.85
C:ONSTRUC'I2ON rr4 .101-000-41.8-000 S61".00
MECHANICAL FEE t01-000-4:21-000 555.50
ELECTRICAL FiE 101-000.420-000 $140.74
1711M11AINGT 1E 101 -ON -X419 -f.00 S1�kt.t10
STO ►it's .NIAX.ION .FEE - RE SID 10 0-1�)(�)0-241-00th 31:1.61
GRADINO FEE 101-03"1.13-000 5211100
iNi:'RASTRLICTME, FEE 225-000443-342 $2.562.73
nRT IN PUBIAC P.I.10ES -RE-81E 701 -000 -?55-000 $40.33
SUB -TOTAL, CONSTRUG170N AND PLAN CHECK.
$4 258.76
LESS PRE -PAID FEES
$0.00
$4,259.76
JAN 0 8 1996 .
By
RECEIPT +
DATE
BY
Da NA
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APP VALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck Z
Exhaust Fans
O.K. to Wrap U
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath Y.6
Final
Final
BLOCKWALL WROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping ILI
Plumbing Final
Plumbing Top Out I t p p
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
jV
Final
Utility Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 12/22/95
No. 13986
Owner Name Century Homes Communities
No. 79-355
City La Quinta
Tract #
Street Camino Amarillo
Lot #
Type of Development Single Family Residence
Comments
APN # 604-192-012
Jurisdiction La Quinta
zip 92253
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 /ex mpted by Ellen Patino
Signature POW
Te?ephone 619-360-7464
Payment Received' $3;,2$0..01
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