9608-016 (SFD)61
b
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of th6 Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor'.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Co ntractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, �e
'i� owner of the property, am exclusively contracting with licensed
contractors to construct 1�he project (Sec. 7044,,.Business & Professionals
Code).
Fam exempt under Section, B&P.C.�for this reason
Date Sign�ture of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm ui�ider penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of corisbnt 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 3ZP..940HtNAL,,abordiode, for the performance of t,�,@q=rWortwhich this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for 51 00.00'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, arid agree that if I should become
subject to the workers' compensation provi'si6ns of Section 3700. of the Labor"
Code, I shall forthwith comply with those provisions.
Date: '2 Applicant—
Warning: Failure to secure Workers' Compensation cdverage is -unlawful and
shall subject an employer to criminal penalties and �ivil fines up to $1.00,000, 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 persor� at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, 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 1)6r�oses:�
Signature (Owner/Agent)
Date
PERMIT # CONTROL#
BUILDING PERMIT 3823
DATE VALUATION LOT TRACT
JOB SITE 79-265 CAMINO IKOSAWIL
APN .6414-190-012
ADDRESS
OWNER
CONTRACTOR DESIGNER I ENGINEER
I
CENIURY CROWELL cIr"MULON."IM-11S
1533!80. D" 9VRE ET q'E. -200
1335'SO. "ID" gt�(teu, Sm.... uw
SAN BE'RNARDIN, CA' 924(W
SAN BERNARDINO *C.A W408
f.9(WIM I _6007
(909)381 .6007 03t,"t 7120
USE OF PERMIT
SING11,11,* f,AAW,,YDWVU,ING
LOT 72 01CR %I)
POKCJ4fPA'I'10 3F
0ARAGWARPOW117 500AKI. SF
WrIMAIIA) COST Or' CONSTRUCRON
10,971.20
CON3TRUCTIO, N FE F 1014XXJI�4184ft
1,"I.AN CHECK.11VE 101 -OW -4391-318
M WIANICAL FEE 101-000-421-OUO
10 1 -ON-*20-000
101-0W,419-000 $14 1.25
STONUNNICITION FEE'. =7 11.) '101-00-24141" $116. If)
GRADING f IrX, 101-000,423-000 $20-00
I N FR A 5 T R tX.11 3 R R FIER 'W -MG -443-342 Q
ART TN PV8LtC111,ACR,.S -'RESM 701 -000-255-000
SMMU C011118TRUCInON AND PLAN CHECK
$5,747.71
'2S
LESS PRE-NUD FF
S0.00
to, P KIM I T F EMS 1) V E T40W
$5,747.71
AUG 0 1r;1' 9 6
.
�RECEIPT
BY
-DATE FINALED
INSPECTOR
]DATE
!�A - ,
. .
I '. - J
17,
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K to Wrap '0.
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Patty Wall Insulation
Condensate Lines
Party Wall Firewall
E)derior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWAI PROVALS
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
ShowerPans 100.1/ J*
O.K. for Finish Plaster
Sewer Lateral L —j
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 1 66141
ELECTRICAL 'APF(ROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Extenor Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
ice (PermL
Notice:
Document Cannot Be Duplicated
Date 7/29/96
No. 14750
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Crowell Communities
No. 79-265
City La Quinta
Tract #
Street Camino Rosada
Lot #
Type of Development Single Family Residence
Comments
APN # 604-190-012
Jurisdiction La Quinta
zip 92253
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 1.84 x 2,436 or $ 4,482.24
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 Foothill Independent Bank Telephone
Name on the check
By Dr. Carol McGrew = '^
Administrator in Charge
Fee collected /exempted by Ellen Patino Payment Received $4,4&2.'24`
1 Check No. 530674
Signature L
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