9604-089 (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 ,t Exp. Date
/Date �'��� Signature of Contractor//l r �
OWNER -BUILDS . �DECLAfiATION
Z V
I hereby affirm under penalty of perjury thatl 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 (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section;' B&P.C.,fogr this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of She 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:
Cartier Z N11111NS. CO. Policy No. �N)42i)66W!
(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 workers' compensation provisions of Section 3700 of the Labor
r
CodeI shall forthwith comply with those.provlsions..
Date: U/, �z Applicant
Warning: Failure to secure WoersCorrip tion coverage is unlawful and
shall subject an employer to criminal p nalties 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 Buildingand 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 rgsult 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, andState laws relating to the building
construction, and hereby 'authorize representatives'of this City to enter upon
the above-mentioned property for innsspecction purposes:'.
Signature (Owner/Agent) `�� f Date/,< .
BUILDING PERMIT
DATE 4/19196 VALUATION $116,76 7.40 LOT
JOB SITE
ADDRESS 70-145 1.1k Ll RIF, CIOU K1,
OWNER
1531 S%). 111", Sri., ow
SAN 131-I .Nt1f_tDIN, CA 924019
(V4.)A8 3 •fl(10
USE OF PERMIT
DO%1,HEYiFi',T,Ai)f,fifN' ANt:t€tXE'
PIAN ; X"R.
PERMIT #
IW14.099
J� 7
APN
CONTRACTOR/DESIGNER/
CONTRR�OL #
TRACTi;Fi'j 1141 i 1 17
5
ei0"4X008
B35 SWI)" )" >KIR174 M, 9200
SAN BEKNAt113]NO CA 92408
r t)�3i�fi1-r>0f}7
0,131,4 V70
.11IENJAlt:IN A('WILAR A 3,si3'.
�W PAS.Sf°LRO "H.
,01o.Ho Sf.{
GAP.A1r# ,JCARP0,RT 3w).00 SF
`�1� "a~' ��ii Cf3;�1' iii ` C�t7l+f5ii iJC�I ia'i+i
1.1.6,767.40
VERMIT 1+FF SUMMARY
:'t LAN M!? C..K VH0
101
CO. NSTr+.C,1+~TIC N int:
101-000.11,8-000
A+ti,C�.4ANICAL FEE
10:1-00042 i -000
�7.isi►
1.kC."t i2d�'At. F
1 U1.-000-420.000
120.63
I'I.UMUN(i Fi:�
133-t1}-41A�Of>D
3:1d13.(D(1
Srco r, Mail 01,1Tk7L;-1~ 710)
101.000-I41-000
t31tn131 fe; iC
10t-006-423.000
V20,00
I2 t f#. i'i�tlC i C 1i24 fi
X225-000.4431-342
Uf527.27
AOT RN:k'1�'11'!�IC P(,ACF.S REIR r, 701-{ 00 -ti -5.000
541,9Z.
SUB.,
AND PLAN :;:fVIC K
,ESS PRE -PAM DESS
'AL ]1.'AMi.ii f FEE, S DUE NOW
f RECEIPT �•,„DATE BY I DATE FINALED I INSPECTOR
I `J
$0.00
$4,301.69
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.
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
ot
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWAL
AP ROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING AP PR VALS
12
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAK 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)
V`
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 APN # 604-343-008
No. 14355 Jurisdiction La Quinta
Owner Name Century Crowell Communities
No. 79185 Street Laurie Ct.
city La Quinta
Tract # 25363-1
Type of Development
Comments
zip 92253
Permit #
Log #
Study Area 230
Lot # 27 Square Footage 2010
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 1.72 X 2,010 or $3,457.20
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 rTelephone`N I is
Name on the check -
IT �, Z !I
By Dolores A. Ballesteros
Superintendent r7
Fee collected /exempted by Pauline Pearson Payment Received $3,457.20
LA�Check No. 24015
Signature ��J p�y�.
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