9510-067 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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. 314473 13' 15106
License y# c Lic. Class Exp. Date
Date SignatureofContractor,,° _..`.
,,ice r�M ...- >'""` �:�� _-•, "��,..-.y."""""
OWNER -BUILDER DECLARATION:"
1 hereby affirm that I am exempt from the Contracto'r'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).
( ) 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 secti,Qp nQed 0gt lejcompleted if the permit valuatio(Vis'f0r $100.00 or less).
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 $100,000, in
addition to the"cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at.
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees. f
2. Any permit issued as a result of this application becomes null and void if l
work is not commenced within 180 days from date of issuance of such) G
permit, or cessation of work for 180 days will subject permit to cancellation. J
I certify that I have read this application and state that the above informati6H is
correct. I agree to comply with, all City,.and,State laws relating to the buil;$ng
construction, and hereby authorize represeritatives of this City to enter upon-
above-mentioned
pon,above-mentioned property for inspection purposes.'
Signature (Owner/Agent) Date1 �� ;j•
.ti f
ALC'
WILDING PERMIT
PERMIT45,I>•0.7
DATE !91 t9r
VALUATION .Yi.lf.4"i A J,4 -U LOT OL TRACT
JOB SITE ADDRESS . 44_24() OCOUL.L0 DIU E
APN 604-:193-00.1
OWNER
CONTRACTOR
CFNTMY H10ME.�.. r'OMM-UNi'f7Y.$
CETINM KY HOMIES COMNIMMES
u,Boum 6 s�.,rlr:r noo
U-240 0CM11.LC)DRIVE
SAN 13.ERNAIZDWO CA 92408
SAN BERNARL?1'Nt CA 92408
(909)'3$1.-6wi t:K11 2120
(909)381-600T
DESIGNER/ENG[NEER
FI? Al*l.K 4301d'LA V) S a A SOS:' XI'-
1336 EAST Cl"sAPM'F.14AVEW013
USE OF PERMIt'iIF4ULh.1'Ai'v1WE L NU
nQ ANOW PA 0 " . tiflr1i51'3 i�3i 3�i'
PI-A.SE31B PLA -1,I4
^r
FEE DESCRIPTION
FEES
'1 R AAT C 0.NS"i'Ril01C7.N 2,4 6.00 S
1'OIRCK?A'170 168.00 SE
GA kOWCARPORT 590A0
THWATED COST OF CCit�NSTRUCTIOi�1
PERWY FEE SSTM°(ViAR1i
1��Vr/.9A��� x IEV, 101 .(t�/��tt�1-4!9-/1}(1 R
ryC.pHTIV���:•,t 7_ �
COIa',,'.1J`MITI'ONV T_.l. 101-000-441Cr-Ml) D?riM.u�
MrSCH"IC;AL r EE 101-000421-000 149.00
1`.1:EC TRICAI. Fly: 101-00.420-000 $160.56
P.1.1 CIVf1'i>N(! fes, 1(J i,-Q1W419-MO : $150,40
S':'OP:4, ;LIf1'riG`;v' 1TIs - PE SID 100-()i)(),241-000 $1_4.61
GRADING ADING r9E 3-00U $20.04
FEE 2254M443-342
AR 11V PUB -11C *T -K-1 S-:RESID 701-000-255-000 $:115.18
SUB-WfJ-.L CONSTRUCTION AND PLAN CRECK .
$3,1214.47
L1vs5 PRE PAID CFsMS
$0.00
D TOTAL PE f FEES DILIE NOW
f
Ocr 9419
$5;214.47
S
RECEIPT
D9TE
BY
DATE RNALED
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath /y
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 /3
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 A."
Utility Notice (Perm)
DESERT SANDS UNIFIED SCHOOL DISTRICT
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
Date 110/23/951 Type of Permit La Quinta
No. 113794 Permit #
Log
Owner Name Century Homes
No. 4 240_x= ,,Street�Ocotillo-Drive_,.,.._
City La Quinta Zip 9225^•'tea 3~ Study area 233
APN # 604-193-001 Tract # 24517 Lot # 0 Square Footage 2436
Type of Development I Single Family Residence No. of units
Comments
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 timie 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 2 436 or $ 4,189.92 have been paid to D.S.U.S.D. for
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 Tel-C�6hoie'-'909.:381-6007
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by
Pauline Pearson
Signature PXA J&f&4„`p � p .P LAA
Cp
w 4, ::�
Payment ,Received'
$4,189.92 -Check No. 101138
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