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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 the Business and
Professionals Code, and my License is in full force and effect.
License, Lic. Class Exp. Dat
�l�ilk� 13 1,$I�tllza�_.,
Date r t Signature of Contractor'^
OWNER -BUILDER DECLARATION'S
I hereby affirm under penalty of perjury 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 is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with, licensed
contractors to construct `fhe 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 3J00 0� t elLaborode, for the performance of ttLefw,aorlk��lwhich this
.,a.iY� .1 i Y..i, u
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 $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: r _ Applicant
Warning: Failure to secure WOfkerS' 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 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 purposes.
Signature (Owner/Agent) Date / t 1
PERMIT" C°NTR°`#
BUILDING PERMIT 9608-0193831
DATE - $12/4C VALUATION .S109,658•40 LOT: TRACT
JOB SITE W-320 CAM tNO WSADA
APN :604-194WI.4D
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C.E't, k IJRY C.;Z.O'iV.ELL COMMUNITIE:
CErN`ruiiy Er;l:t}t4{ab. t;'C)11mtJwrm.-,
1535 SO. "13" 5'T'i21 I,`T, S'i'ts -11200
1535 SO. "ll" Si'REE1, 91'Ei. #200
SAN BRINAit.[7W, C'A, g2409
SAN E3ERNARDINO (:A, 97.408
(909)391-6007
(900)3,81-W07 2120
USE OF PERMIT
SNi, U PAAPILYDtA/Llsl.oiNG
.65,r 85 nio Sly
0A.RA.(AYCAKJOR'I' 5970) ,SAW
/
tv.5'CTl<9, . 13 C�(W Of Uig 'T.181►�:.~f1074
1li9,l;.�f .40
VKDtMIT YPOr, til; IMAIARV
C0KS-1`_I3: X,`r10N Ws 01-M-4134*0 $674_50,
VILAN CHECK FIER 101.000-439-318 $565.16
fV1 CHANICAL.6 tE 1.OI.-P,{iii-ilii-U00 $60.0
F1XC1`T(1CA1..F13F 51:2.3.5$
KIA411INCt 17WN 101-0(1()-419 000 $148.00
3 rCNE"r ;11C+1'1EJ1� `1?C,_ .R1 SID 1-01. 00-141-000 $10.97
C.R AD.IW F A-1 101-UUO-42:3-000 $20.00
1td1+'t2Art`T WC'rUR.R I"F:F 2i5'4)00-441-142 S2,467.11.
ARI 1N P(IM.(C .ACf• S - RESIC 701.000 -255 -OW S t.15
SUB -TU E.AL CO.NS'i,l?.1'.lG" ETON .AND PLAN CHECK
$1,01►3.v7
LWi.S P:KE-PRAEO VELIS
$0,00
1.., 'd'AL P:F;It.A1 11' FirV3 :i�. E' ,NOW
S4,093.67..
AUG. 0 9 1996.
By
RECEIPT
DATE
BY
D TEF AL ED
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 Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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 1/eA
Utility Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 7/29/96
No. 14753
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Crowell Communities
No. 79-320 Street Camino Rosada
APN # 604-190-010
Jurisdiction La Quinta
City La Quinta zip 92253
Tract # Lot'# Square Footage
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area 233
1E:IIL'1
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 1,804 or $ 3,319.36
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
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected&mptedbby Ellen Patino
Signature
Payment Received
Check No.
Telep►`one_,
J.
$3,319.36
530674
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