9604-888 (SFD)LICENSED CONTRACTOR DECLARATION
"thereby 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
Date j 11 f� Signature of Contractor
E
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am ex6mpt from the Contractor's
License Law for the following reason: I
( ) 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 exclusivel�,.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 '16f 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 /j.7,Ni'('F.l.Nj ,& Clf3 . Policy No. `Lti ;G0669(1.t.
(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,R nd ag"ree/that if I should become
subject to the workers' compensation provisionsofASection 3700 of the Labor
Code, I shall forthwith comply with those provisions. ,r .
Date: 1 Applicant
Warning: Failure to secure VV. rkers Compensation coverage is unlawful and
y. �° X I
shall subject an employer to crriminal,pe�nalties and civil fines up to $100,000, in
addition to the cost of compensati9n, damages as provided for in Section 3706
of the Labor Code, interest and Otto/ey'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
�forinspectionfpurposes.
/ /� 007,
Signature. (Owner/Agent)�,�*
PERMIT # CONTROL #
BUILDING PERMIT W1114 01143 ' 3174
DATE 4/19ft VALUATION - 393?47434) - LOT . 226 TRACTj363_1 }' U f
JOB SITE
ADDRESS 79-180 IWURU COURT
IOWNER
APN 604.343-07
CONTRACTOR / DESIGNER / ENGINEER
CUM"r13 Y C".CtOWMA, C OMAIUW.1113.1 .. CliMiJRY CRONVi 1J, CON! NYWME. IS
1535 S(3. l)" S"! .11 EIVI", S1,r, M160 _ 1.335 SU. TY SI -k T, STE,9.2500
i`500
SAN RERNIA WIN,CA 92*18 S,, NBERT+1ARDIN(7)� CA 92408
i+K3�;t3131..64(J'l.6W-7 MA 2120
USE OF PERMIT �" "• ^ "�. v"^^
!i1Sk'vfl4} A�aCilGFli ASSOC.
SINGLE. If<`ANl LY DWFLNJING °i459 M'.1 ii,^`7n 0 AVE,
13M kCd Yt Y! LA IQVIIWA Nt;J1t ril
PLAN 3.0
`ltd,e'iG"!'C~I71d�(JG"d'f>N
0ARA.(3 JC*AR:Z,R'1' 3f+
EX-firvIATED C0S t; F.C'UN eR(fCrf1011
99,47430
"1i.4N3 CMEC_14_ 1+x+.1,kC1
;.a1lD- ?t9 't fi
$ ►3 .16
CONSI1 UC CION
.f;'1.1:iC RECALVW�'.
101-00.0.420-000
!Pf',�Jiv�l31N� 4�1:1�
1!1#-(.�i-rttQ-(100
�!4f3.l1t?
«r�'CSty 1M.C.1'1'ION ILEA -,kt U°
1014)00-241-000
INIVRA 3'1'1tUC4Uni F9:t"`E
50-443-342
SUB -TOTAL _CON IT1 RU3 ON AND PLAN CREC:K V1.730.23
LESS PRE-NAIU FFIGS $0,00
AP7Ttff-Aj, PERMIT; r, le, US OVE"NOW S3,730.23
2:3.M6'
RECEIPaTDATE,z, BY DATE FINALED INSPECTOR
C;>
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
6
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 Wall Firewall
'
Exterior Lath
Drywall - Int. Lath
Final
Final
10
POOLS - SPAS
BLOCKWALL A
PROVALS
Steel ,
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final,
Gas Piping
PLUMBING APR
VALS i
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
p�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
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 Z"
00f
Utility Notice (Perm) -7772WY70 Z.1-11,07,
A
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 4/18/96
No. 14353 Jurisdiction
Owner Name Century Crowell Communities
No. 79180 Street Laurie Ct.
City La Quinta
Tract # 25363-1 Lot # 26
Type of Development Single Family Residence
Comments
zip 92253
APN # 604-343-007
La Quinta
Permit #
Log #
Study Area 230
Square Footage 1663
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 1.72 x 1,663 or $ 2,860.36
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 cc/Foothill Independent Bank/Topaz Associates ` Telephone ? ;
Name on the check
ell
By -Dolores A. Ballesteros
r`
Superintendent
Fee collected /exempted by Pauline Pearson
Signature AL," 9 I 1\1 A A �
Payment Received $2,860.36
Check No. 24015
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