9604-090 (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
1061137
/,Date '' Signature of Contrac orl
OWNER-BUILDA,DECIILARATION -t
I 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 (Sec. 7044, Business & Professionals
Code). t
() I am exempt under Section k-- - B&P.C. for this reason
Date Signature of Owner '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury oneeof 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 7.FNI'.I'I•.4 IM, CO, Policy No. 2042ii)6%i.
(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 ofrSection,3700 of the Labor
Code, I shall forthwith comply with those provisions. Oro -
Date: r -•'� Applicant 7eV e�
L� / . tGp
onWarning: Failure to secure WOM4ronsaticoverage is unlawful and
shall subject an employer to crlminaHplenalties 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 authorize representatives of this'City to enter upon
the above-mentioned property for
'inspection purposes.
Signature (Owner/Agent)���� Date
BUILDINGPERMIT PERMIT# CONTROL#
1176
DATE 4/19/96 VALUATION 987."5," LOT 2R TRAUIM: 4 (11
JOB SITE 79-19.5 LAURIE Cl/UK
APN 04-343-009
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C ? M t:'t'Ri 1.'�rl:C. , c�;��4; 9t il`r!'!`tis�
C 111* UR:yC001V
1 533 SO.."D" 9 Imo' f'.1; r„ SIE. #200 '
13.35 SO. "U' 9ME4--T, SrE 9200
SAN NERNAR.17INt CA 92,109
SAN BERNAf DINC) CA. 924101
(Ng1381-6007
f909)3181-6007 et -If 1# 2120
USE OF PERMIT
SfNi11,1 PAM RX iZ%VI LUNG
DE I; X2EN' 4r,' LA QUf'NTA NORTQ
PLAN TXPR
T ACr CON!fi' RUC•.iION ; 1,461.00 S
P010,34MATIC) 36,00 SF
S
ESTIMATED COST OF CO7YM%iMION
Y,'If,it11'1i T FEE NUINIM'AR"V
MANC,'UHICKFEE -000-419-248 $486,86
CONMATUX110Nl`IX 101.000-4'118-000 $585,50
Ml:t'IJANWAI.. F1."sir 101-600-421.6170 $47.00
,f?1 EM'RICAL FEE 101-000-426E-000 S1fa7.fKl
t IAIM1 140 f• i? €014)OD-419-001) 5118JO
ST +NK? MO"t (ONO M - RE -SID 101.000-241-M. 1".79
101kADINO F01 10f4AA-Q.1yt1 Q S20.W
JN RAT RV,'"i.)KRxi?.ki 225'000.443-342 $1,917.11
I WI3-`IWALCONMUC'rIONAJNU PLAN CHECK�3,3dI.tG
USS PRE -PAID PEES
W.00
T 'f' L PERMIT FE&S' DUE .NOW
APR ?,
RECEIPT
! Bvl.
DATE 1
I.;�._ -
BY
DATE FINALED
INSPECTOR
4 ,
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
69
Exhaust Fans
O.K to Wrap
If
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
f 117
Final
Final
BLOCKWAL APP OVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING AP RVALS
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICA AP OVALS
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 j
Utility Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 4/18/96
No. 14356
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Crowell Communities
APN # 604-343-009
Jurisdiction La Quinta
No. 79195 Street Laurie Ct.
City La Quinta zip 92253
Tract # 25363-1 Lot # 28 Square Footage
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area 230
1461
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 1,461 or $2,512.92
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
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signatureo P, q__ A1���CYy�
Payment Received $2,512.92
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