9908-141 (SFD)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. Date
t.Date Signature of Contractor
OWNER -BUILDER DECLA ATION
l.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).
( ) I, as,owner of the .property, am exclusively contracting with licensed
contractors, to construct the project (See. 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 z 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.
GOL DFN EAGLE MS, ��VdC �rt�i9ti9-►13'
(This section need not be completed if the permit valuation is for$100.00 or less).
( ) .1 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 t��a wor Cbmpensati rovisions of Section 3700 of the Labor
CO�e, I s TI •o£'th `ply with(those o ' 'o
Dater APPllcant
PN. •
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby .`made to the Director of Building and Safety
for a permit subject to. the conditions and 'restrictions .set forth on his
application.
1. Each person upon whose -behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result 'of this applicaton agrees to, & shall, indemnity
& hold harmless the City of. La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void -if
work is 'not commenced within 180 days from date 'of , issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City; and State laws relating to the building
construction, and hereby pjthorize representatives of this City to enter upon
thee above-mentioned pro e( r inspection purposes.
trSi, ature (Owner/Agent) Date °' •`
BUILDING PERMIT PERMIT�#���
DAT r/ IJ, �VALUATION, S1 IFDifiL�97.'�i LOT TRACT 201 S8
JOB SITE
ADDRESS/( t -LCVis� �
APN 769— 2.2-039
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY CROWELL C:OMIv> CN TTES
C:kNiU Y C;R:OV/ .Lt COMMUNITIES
1535 SO, "D" SIREM', C, SM 4200 :
1.533 SO. "D" METT, S M. 4200
S, BER.1` ARDINO C.A 92.408
S.A.N�1:$.ERNARD.INO CA 924(813
•
(909)38I_.--6007 C 8L# 1120
,
USE OF PERMIT +
1li`FGLE FAMILY ONV13I:.i.rt.NG
&FT) - LOT N(.Yr Y:Pit✓I UDR €�L%C`:� L�Ir��I
O�tl. L'i3Ltt�, ?"•�In 9tE,tit:fC:'1'+v)N t3N PL,A'iY't;1:IirCY� k�+d; Q4t IbttiL7'[P.t.� ` , ,,•�"`�
ISSURAN E OF SANTE PLAN TYPE.
CLIS°C(.FM C'01KI ''fRUC"°rt+' N 2,107.tlO 'sb
"' t .� z'• s;
PORCafiiIPA7I'!O 2106.00 SIP
G.A'KAGMAXPORM 4' 4.0:7 3i'
nCr 6�yp �p �+�^gt ,��y.p. el �r,t�P,�y�r'9' C�7;Ys1� p�
�b.JOYA iJ�y O.'sXivn,Y.R��N'il V.. ll�49�[�
•7�p�q.�g,Q,.p-
�q
176,2,5 .5,
�tgp�ry SUMMARY
if.Yi1Li17R.1 iC ,C!.EE �Ylf:P#�if.tR.il Y
CONTrRRUC;'T3ON Fal 5909.00
PLAN CHECK M- €.!�4-tFt� X139 31� $187.62
INIRC'Hit• NTCAL FW, ]Ol Eii90 2f Dfl $98.50
.
0 ',FCVRtC4U; P'E- 101 4XV-42.0 •tro0
[' LI7lsr[BIN
«�`fP.fJ•I�YO�I'G��f'iO:t�i�l�-:4YstiT.StO 101,•QQ(b-�d1�A �.a.7.6b
UtltAlJ NQ FEB 3fDl�i7tit��t23-lfilil 6°7�.fetf
AFLT Ito PUtLALIC PUNCE3 - RESI 01-t 00( _73347W S61!Sl.:t9
DFVELORZ-R INIPACT11ER1,�3fi7.Oti
STJ11210:[AL C,'0N'7'11x;C Ti0 AND PLAN CHECK
$3,634.90
!
RECEIPT
DATE
BY f
DATE FINALED
INSPECTOR
,.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I"%
Underground Ducts
Forms & Footings
Ducts
Slab Grade
/.7°- GI
Return Air
Steel
Combustion Air
Roof Deck
.— � =� �'
Exhaust Fans
O.K. to Wrap
— Q —OU
F.A.U.
Framing
_s/ p v
Compressor
Insulation
Fireplace P.L.
�` cr�j �t
Vents or
Grills /
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
^ Cr0
Drywall - Int. Lath
Final
Final
— -oa
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Hacks
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
Ag .-/0--9
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral/
Sewer Connection
2_� 0
/ ` N
Pool Cover
Encapsulation
Gas Piping
Gas Test
2 —,7v 44�1-
Appliances
Final
COMMENTS:
. plCftQ.. $ .5- i�nv 6 kt asc-rte..
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 —pti
Utility Notice (Perm)
CENT'UtRY HOMES
Century Crowell Communities
i
A
a, fir.- •
Tract Name J'o
Tract # a
Lot
Phase
{
e on the
above referenced lot
will be done by outside subcontractors,. �F7"62. (5go"0vo
a
es Agent / -
Z d
Date
1535 South "D" Street, Suite 200 - San Bernardino, CA 92408
(909) 381-6007 FAX (909) 381-0041