9604-084 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
A 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
i—1 +111 15 ��,,.s-�• 1 LOW-- 119 /
el
r
Date �
_ � �- � Signature of Contracto iii
OWN ER-GUILDER,bECLARATION
I hereby affirm under penalty of perjury . at 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). l
() 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 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 • 'Policy No.,
713Ni'M IN& Cts. I 2(420t;690I
(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 SectOWj7f00 of the Labor
Code, I shall forthwith comply with those provisions,/r.,�'` �*
Date: !�/? Applicant
Warning: Failure to secure Workers' Com e sia overage is unlawful and
shall subject an employer to criminal penalties/s 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 ori ' 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 Sate laws relating to the building
construction, and hereby authorizerepresentativesof this City to enter upon
1 the above-mentioned property for I�nss6ection purposes. ]
,Signature (Owner/Agent),'_A /" Date +' 2
BPERMIT# CONTROLk
BUILDING PERMIT
44 3170
DATE 4/19 {► VALUATION � 7� �. LOT ` TRACT. ,Rl>; I Irl (1
JOB SITE ADDRESS Iy'-,226Lt1,1i R.l�'.C.OMI APN Otte-.3+l.1'-1ft1�
OWNER CONTRACTOR / DESIGNER / ENGINEER
*.41'A 16 .t,.,
i .;S 5O.
SAN 11•FRNAkIAN, CA 1�2408
(909)181-(a i
USE OF PERMIT
V
I)EL Rn* (iXt LA Q1+1 N'I'A NORTH
PI.AN'yNN. 41t.
'I•KACI' C0N8'1'P.( )U CION
PORCIVPA` TO
GA[tACIIICARPORT
1♦L':�r.�1� M.M.I.
15:x? SO, "D" 1 ii.1:1: t; S17i. ff2u()
SAN BERNt NDIN() CA 92409
rIBUft 2120
11;-uNJ VtIN AGiTTLAR ASSOC".
5459 11A.33E R0 AVK
RRn'-RNIDI'— i_'A 50Z!05
3f,t)0 `;Er
4 0.00 SF
87, 05.90
rJF 'F '1 F: t��t)P.'S•Fi l tJG"i 1t��t E1t�IL� r�r,llcd CtIl C1: $3.;11.16
SS PRf:-1'AFf1 PFii:.S 3►n.(iA
LE
APR a 3.1996=Yi'M, PERMIT r'%:V,IS cu. R NOW $3,341.16
RECEIPT DATE . BY DATE FINALED INSPECTOR
PERAUT :F+'1~aRt?MMARY
In -AN (^1 : lillyi;,
IfI)ti-!(Ny1fflf-.♦�t�p1-/3V1v�3i
$43864"
irill.
E"t
a„ (,�i�'a d�Vt. i�l•Ji! �� [ir.1
1 V 1'i.ilV'-! f [i-Vt/l!
� W ;5 �ii
NIECtIANWAL FLU
101-Cff?(1-4214**
$47.0%)
El..fECTR.I CA1.0iti
1014)0420-000
S I u7!+t1
pf,TwQfmw
'511$go
- M114r, N101 tt N I'RH-12ti.`UD
101 -WO -i 41.0
Ski +9
01t,A01NC F1!)1
101•t'11}G-42r3.000
2 ►.clij
INrRAIti"1 RUC.": VRE FE1'
'225-OW40-342 40-342
$1,467.11
87, 05.90
rJF 'F '1 F: t��t)P.'S•Fi l tJG"i 1t��t E1t�IL� r�r,llcd CtIl C1: $3.;11.16
SS PRf:-1'AFf1 PFii:.S 3►n.(iA
LE
APR a 3.1996=Yi'M, PERMIT r'%:V,IS cu. R NOW $3,341.16
RECEIPT DATE . BY DATE FINALED INSPECTOR
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. r '
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath _
Drywall - Int. Lath
Final
Final
BLOCKWALLP ROVALS
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 APf R VALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping iI
Plumbing Final -
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral YaPool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
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)
COMMENTS:
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. 14349 Jurisdiction
Owner Name Century Crowell Communities
No. 79220 Street Laurie Ct.
City La Quinta
Tract.4 25363-1 Lot # 22
Type of Development Single Family Residence
Comments
zip 92253
APN # 604-343-003
La Quinta
Permit #
Log #
Study Area 230
Square Footage 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. .•�� ; =r ; �,
Fees Paid By cc/Foothill Independent Bank/Topaz Associaties Telephone;
Name on the check
By Dolores A. Ballesteros , w
r
Superintendent
'_
Fee collected /exempted by Pauline Pearson Payment Received $2,512.92
(� Check No. 24015
Signature A.A A LA 0 . L�J✓Ul��
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
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Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting