9803-103 (SFD)LICENSED CONTRACTOR. DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H _ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N co Professionals Code, and my License is in full force and effect.
O D M License # Lic. Class Exp. Date
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U CD
OWNER -BUILDER DECLARATION
Hd 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
0) License Law for the following reason:
Z ( ) I, as owner of 1he 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).
MO I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
ON
Q WORKER'S COMPENSATION DECLARATION
IL
QI hereby affirm under penalty of.perjury one of the following declarations:
H p () 1 have and will maintain a certificate of consent to self -insure for workers'
K W �: compensation, as provided for by Section 3700 of the Labor Code, for the
n J Q performance. of the work for which this permit is issued.
Q (� (,p I have and will maintain workers' compensation insurance, as required by
j o Q Section 3700 of the Labor Code, for the performance of the work for which this
L' LO H permit is issued. My Workers' compensation insurance carrier & policy no. are:
'IT z Carrier Policy No.
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g (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 wo kers' compensatio v'sions of/le Ion 3700 of the Labor
as,o ' comply vr�I _mss 'si R§.
kat-1.Applica
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 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 representitives Of this City to enter upon
the above=mentioned,propertyf pe ion orposes.
ySignature (Owner/Agent. 1 Date,/�9' W
BUILDING PERMIT PERMIT#
DATE VALUATION &186,761,40 IT TRACT
7^�
r
JOB SITE
APN
ADDRESS
-375- 'E
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C,'EWIVIly C:f;.Ot"ELL C:t:)I:iMUNITI,`.;
CEsPJ111.113. Y C l:i)'ttr?I..C. t:" r , >> 1� cr
1. (.)&1wM; 1N1H1ES
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SAN HE'R1qAIt.DlW0 CA 92.408
SAN l;iERNARl:itt:lO C:,A. Q2408
tIXY9lV I -6007
USE OF PERMIT
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�,•d„I;f P,fa�
RECEIPT
DATE.
BY %
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
A
Combustion Air
Roof Deck
- Z
Exhaust Fans
O.K. to Wrap
_ q --4
F.A.U.
Framing
—t s— tar,
Compressor
Insulation
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
e
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROV LS
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
16 ._ Z — f—
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
GY.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Notice:
Document. Cannot Be Duplicated
Date 7/22/98
No. 17359
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameCentury Crowell Communities
No. 45-345
City La Quinta
Tract #
Type of Development
Comments
Street Carrie Lane
Lot #
APN # 604-375-002
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Square Footage 2;010
Single Family Residence 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
1.93 X 2,010 or $ 3,879.30 the property listed above and'that building
permits and/or Certificates of Occupancy for this square footage in this proposed project•may novo be issued
Fees Paid By CC/Foothill Independent Bank/Ed Knight Telephone;
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $3,879.30
(J". '- Check No. 604539
Signature
NOTICE: Pursuant of Aftembfy BIII 3081 (CHAP 549, STATS. 1996) this will serve to rwtity you that the 90 -day approval period in which you may protest.the fees or other payment identified
above will'begin to nm from the date on which the building or installation permit for this project is sesued or on which they.are paid to the Oiatrict(s) or to another public entity authorized to
collect them on the Dialii*s)(s') behalf, whichever is earlier.
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