9604-091 (SFD)LICENSED CONTRACTOR DECLARATION,.
s, 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 # A Lic. Class '•f Exp pate
71
13 1197
loo
iDate'°%� Signature of"Contractor4z s��•'-
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)..
O I am exempt under Section's B&P.C.'forAhis--reason -
Date Signature of Owner ;
WORKER'S COMPENSATION DECLARATION ,
I hereby affirm •under penalty of perjury one ofiih�e following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided forby Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued...
( ) •1 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.J?,I`l:t'iM MS. -CO.— _ 'Policy No. - %i `feiotib+tik _.
(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%gree„that if I should. become
subject to the workers' compensation'pro isions of Se6tion,3700 of the Labor
rCode, I shall forthwith comply with thole provisions
,Date: Zl;,*Z Z Applicant • ”
Warning: Failure to secure Wor, ers�Compensation coverage is unlawful.and
shall subject an employer to 'criminna1 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. r r.
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, itskofficers, agents land employees:,
2. Any permit issued as, a -result of this application becomes null and void: if
work -is not commenced within 180'daysI'from date of issuance of. such
permit, or cessation of Work for 180 days Will subject permit•to cancellation.
hcertify that I have read this application and state that the above information is
Correct..I agree to .comply with all •Clty4 d Statedaws relating to the building
construction, and hereby. authorize representativessof this City to enter upon
a't s- fir✓ .
the above-mentioned property fopinspectiioon purposes ~..
Si.nature (Owner/Agent Date
PERMIT #CONTROL #
BUILDING PERMIT�dyz X177
DATE 41,.1,9/946 VALUATION 5.104,370,20 LOT' .7,9- TRACT; 43-1 P
JOB SITE S.J<�
ADDRESS'
APN E1�i^�rdQ
OWNER
CONTRACTOR/DESIGNER/ENGINEER
f IENIURY CROWT"LL
CJ?' ' i 111.' C.3 ��'i i L CQ1,N4:1':U;?]T}1:C.
1355 so. "D":I1'R1 ll,11M. ". #200: ' ...
151.E So' "0" STRF.E4r, S 'E. J1200
SAN1 Cl..NA1iOW, CA 924.»,
SAN Bl?RNk M-NNO €,A 5;2.405
1009)381.-6007.
(`�t19j3fil�ffyt27 .-' 11.20 .
JR hi'rliv M AGUTAVt ASSOC.
USE OF PERMIT
$rNGILA 1+tA ILY 1 V5(EL efts
54`9 PASSERCCtAVE.'
Ma, R LKY ftif'LX QT Fiii�t.'!'NC'+F'v'1'E
PLAN 4I'XAh' i
POR.C11W.r.T.* 60.00 SF
C,3.f' .ACi ?IC'pltZf'f #t`T 425M 8F
OF, CONSIUMION
104.370.29
Y�a.��UT FE,,'NUNIivrAR � - - -
-
;
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.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL AP OVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPR VALS
Gas Test
Electric Final
Waste Lines &6
Neater 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 22
Gas Test
Appliances
Final
Final
Utility Notice (Gas) fo
ELECTRICAL ApkOVALS
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)7,41 7-16
COMMENTS:
0
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 # 604-343-010
No. - 14357 Jurisdiction La Quinta
Owner Name Century Crowell Communities Permit #
No. 79205 Street Laurie Ct.
City La Quinta zip 92253
Log #
Study Area 230
Tract # 25363-1 Lot # 29 Square Footage 1754
Type of Development Single Family Residence No. of Units 1
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 1,754 or $ 3,016.88
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
t Name on the check
By Dolores A. Ballesteros
Superintendent
7
Fee collected /exempted by Pauline Pearson
Payment Receive
Received
Check No.
Signature l� ! a Q �;y� q p�A A_A,CW\
Telephone
$3,016.88
24015
rr 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
T