9604-085 (SFD)LICENSED CONTRACTOR DECLARATION
C0 I hereby affirm under penalty of perjury that I am licensed under provisions of
F_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv W Professionals Code, and my License is in full force and effect.
O 0 ch License # Lic. Class Exp. Date
r- dLO
r; w i T
Z Date f Signature of Contractor
rn O I. *�/,
(° °)
OWN ER-BUILDER�DECL/ARATION
W -
Fd I hereby affirm under penalty of perjury that'lam exempt from the Contractor's
(n License Law for the following reason:
Z_ ( ) 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). i- W
co () I am exempt under Section ' - B&P,C. for this reason
N Date Signature of Owner 1
ON
0)
Q WORKER'S COMPENSATION DECLARATION
CL
ur Q Z I hereby affirm under penalty o�perjury one of.the following declarations:
O () 1 have and will maintain a certificate of consent to self insure for workers'
-
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q U ( ) I have and will maintain workers' compensation insurance, as required by
O � Q `Section 3700 of the Labor Code, for the performance of the work for which this
0)F- permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT Z Carrier Policy No.
co =) 2AYN1 TI1 INS, CC), it
�a
J
(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
Code, I shall forthwith comply with those p(rovlsions--!'_',--
/Date: 44” Yy Applicant ef"
Warning: Failure to secure
;,WofkersvCompensation 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, 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 properly4oir inspection purposes. ,/, ✓
h�
'Signature (Owner/Ag� ) Date
BUILDING PERMIT PERM ;# C°NTR°`#
3171
DATE VALUATION LOT ���1i�-31K;� TRACT
4119/96 253433.1 N 1 I -
JOB SITE
APN
ADDRESS 74414; LA1)RWO)URt
6114443 -IM
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I I!.Ir i 11' Y (:r1 -M., 1/' 1.'cos o"u-Ir1''l :
.� . \\J t, nU ��,,,. . ,
::�=*r1� .1' 1' r_'1't 1 '' 1t 1JNr171t`'
.1 �. . \;/..1.11 NC3l . ..,
1?3.1 So. "Vi"','MZi~iii'. ME. 4200
1515 S(J, "13".1 i'it 9r, ME. U200
SAN 14i:R ARRAN, QA 92;H)K
SAN BERNARDINO CR 92,109
t'1iT'al':1fil-t�ti(17
(s"1191-6007 (71311H 12120
USE OF PERMIT
1.�i:iJ1r1411W fi.:�111a.ni� a::�:Nv.
/.,
�N�^i.� 1 t�n111:5' iii t.1,1NCY
944` 11ANtiHR0 Ati'F
OV17t:111 4s, t:'A 9.`u)ti
D0, Ut flR.[,A 00IRPA NQICfH
f'f,�iiJ.1`t11
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1K WC1LfPATI4`.) f t.C+f► SF
C11ARA06(CAk1't' IA 425.00 Sn'
• iv;.�'i'Ihi�l'i'1J�Lcl.�l +3i+"'<"tSt�;S7'dtQJC''fit'iN
1tti3.,�7ft.z�S
IN1Y RMIT PC StTf41MARY
PLAN C.i1'1,CX FTS $555.73
CON'S'l'C UCIrION FIX 101-MO.418-000 36$7,0
N11:110iAN1C'ALi'iks tc�t-acts- zt-ct 5r,s�;
i;iF.f. f`1tit:AY,1'FJ: • 101�1?U-d2Q-(KH.1 � f f8:3'�
1'J,tiIWB(NO FER 101 -0M -4190Y
VrONG NICI SON 14.r1- R SID 101 -ON -241.000 $10.411
GRA.UINO k`id1's 101430423 -ON 520.017)
iCdFRASYMUC; i'�IRE ME 22� -000.144'4-342 52,3+(4.34
ART 1N i'C.Mi IC MACES - Rh1 "I1,: 701-W-2_55000 S7t►,tNJ
4rS"1'1IUCrION-AND .PLAN ClitiCK
'R
KQ37.43
Who
1,E55 F-1'Ai FEES
1'D PR '� ,O,Ci6 OUT, M1i!!W FMS DIM NOW
i
$3.937.43
�-
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 42
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALI P OVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPP OVA LS
Gas Test
Electric Final
Waste Lines 65 r
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Q.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection AK
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
,
t
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduft
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Notice:
Document Cannot Be Duplicated
I
Date 4/18/96
No. 14350
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Crowell Communities
APN # 604-343-004
Jurisdiction La Quinta
No. 79210 Street Lauries Ct.
City La Quinta' zip 92253
Permit #
Log #
Study Area 230
Tract # 25363-1 Lot # 23 Square Footage 1754
Type of Development Single Family ResidenceNo. 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 Telephone_
Name on the check ^; '
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,016.88
Check No. 24015
Signature
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