9510-068 (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
License A t -- Lic. Class P Exp Date
Date ii Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm 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 the project (Sec. 7044, Business & Professionals Code).
O 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 section;n-, 0ddr'dJ 15011dompleted if the permit valuatioNis fori$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: 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
;a?"permit, or cessation 6f work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above informationisY
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizesepresentatives of this City to enter upon ti e
—above-mentioned property forK pection`purposes.
""_�- Data
SignaiDure e
(Owner/Agdyr�' .
AL"
BUILDING PERMIT,
PERIVI"4510 0 68
DATE
VALUATION 3+ E!. a&...7WU
LOT OL
TRACT
JOB SITE ADDRESS 44-2774) 000 f!LLO DRIVE
APN 6641 193-002
OWNER
CONTRACTOR
CFN'9JRY HOMES CO Iii UNIMI ES
C1:NI .rte `.=:C)WS COx DIRT`YNT T,FS
44-270 OCOTILLO DRIVE
"535 SOLiM D..iF , EET #200
SAN BERNARDINO' CA 92409
SAN F3ERNARDIN, CA 92:10
(909)38,1.6007 MY 2120
DESIGNER/ENG[NEER
FP-.WK':xXO1*LA LS Qw:S0_Cx11.TE
1XV) EAST M40PVrAN AV -EIA
USE OF PERMI. i..'a(i ,i.:.;,AIVi• s, Y D' W 461., i La .
ZJ WN F_ CA 926" (904)5242-6978
I2.MCHO OGL T'1I,:LO (i1; .LA Cit, IXt'A NORA-E f
FEE DESCRIPTION
FEES
`i`1.ZAe r C:oNS'.i'ttllt: "rioN 2.746.00 S .V
PORCIVIPATIO 168,00 SF
GARAGFICARIORT 506k(l St'
IJSTfN i ED CO3%T O1F CONSTRUCTION
161,859,50
PF MM1T FEE SVMNL4:1<t Y
PjY , N C;HPX'K, HIR $709.21.
CONT STIVUC1'IOtd;"IM" 101-000-41.3-000 �f3�5.30
WCHANICAL F'FE 101-000421-000 555.50
ELECI"t MAL F a" 101-000.424-000
'PT t;r_MAINrY MR8 103 -000-41.9-OW S 162..00
;'.f 01?iG N.OTIOt i FM � RESID 100-000-241-000 $16.11
GRI A)ING YIEE 101-1000-423-00 192.00
f1NFR ,5TR.UC_TURE FEE 225-000-443-1342 S3,578.07
AP�7. ti�I�RPrT� :tit.! �"5 R -SM 701• W-.5 ^'�t 0 $153.is
;;fi;-1 f?"f tat, CC �`TS fh'�i IG""IaN ,A1ti �� PLAN CIMCK.
55,7720,29
LESS PRE -PAM FEES
O TOTA,1.�� ZpER Md€'1'' FEES 1' UE N -V
0012 4 19
TO FAL -P:>t'103,11, T 1?ir�ii�3:T' FEES
9S
$0.00
$5,7211.29
5,720.2 ►
RECEIPT ^'•e,�.DATE
BY
DATE FINALED
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
Z7
Exhaust Fans
O.K. to Wrap
Q
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
J
Grills
Fireplace T.O.
I_
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
z
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
4
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
Final
Utility Notice (Perm)
COMMENTS:
DESERT SANDS UNIFIED SCHOOL DISTRICT ,
82-879 Highway 111
NOTICE: Indio, CA 92201 ,.
Document Cannot Be Duplicated 619-775-3500
Date 10/23/95 Type of Permit I La Quinta
No. 113795 Permit #
Log
Owner Name Century Homes
No x-44270 Str_eetOcotillo Drive
City La Quinta Zip 92253 Study Ana 233
APN # 604-193-002 1 Tract # 124517 Lot # 0 Square 'Footage 12746
Type of Development Single Family Residence INo. of units 0
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 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 2 746 or $ 4,723.12 have been paid to D.S.U.S.D.
the property listed above and that building permits and/or Certificates of Occupancy fol
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 /exempted byPauline Pearson
Signature QL. a Q ; ;,.� e V i A,A t�A A,-Vk
for
Payment Received
$4,723.12 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
Teleiih6rie -_90W,3£ 1-,6007
f Q
F,
-G
A+
Payment Received
$4,723.12 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