9604-093 (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
t a:
r�,'sILDate Signature of Contracto,- -
OWNER -BU
I hereby affirm under penalty of perjury, thatd am exempt from the Contractor's
License Law for the following reason: Y
( ) 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 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 one7•of ,the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700tof 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 UNITH IN,& CO, Policy No.. 2.04W66901
(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
1,:- 'IFZ
subject to the workers' compensation prow iorirof�S,ection 3700 of the Labor
Code, I shall forthwith comply with thoseiprovisions.
Date: ° �'` /-4 Applicant +
Warning: Failure to secure VV rkers' Compensation coverage is unlawful and
shall subject an employer to criminal realties and civil fines up to $100,000, in
r
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 applicator 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`,4a'nVtate laws relating'to the building._
construction, and. hereby authorize frepresentativesof this' City to enter upon,.
the above-mentioned property tgjr inspeciio purposes.
Signature
BUILDING PERMIT PERMITS CONTROL#
v�rid�t��
DATE ;�t 1 i� f%* VALUATION $87,i11)�5.90 LOT 31 . TRACT, W=_ t � t?1179
ADDRESS 79-.Z.IG.w. 1.�11.iPME CC%��R JOB SITE
APN fMW_J�i�'i_012
OWNER
CONTRACTOR DESIGNER / ENGItNEERy
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$AN 1ii?R)NAE2 IN, CA 9`2409
SAN T3t;RNAI'MINO CA 9140-R
11909.1391.6007
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BENJAMON ACTT) ;RFs, AISSOC.
USE OF PERMIT
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-I"t MA��''RUCTURF. FW 22MM-443-342• S:i,nfi'f.4!
SUT,�-'A)T`'1�, CONSIRUC," TONY AIND'PLAN i�'REC
._.--.. �.,LaS. ►AE PAID FEES
$0.00
TOTAL PENNUf FEES DUE'NOW
:. APR23 19.1
RECEIPT'"' .�
DATE
BY •'
DATE FINALED
INSPECTOR
orl Date
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 j}
Exhaust Fans
O.K to Wrap
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
Final
Final
BL0CKWA1lLPqFPR0VALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP . VA LS
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 4/18/96 APN # 604-343-012
No. 14359 Jurisdiction La Quinta
Owner Name Century Crowell Communities Permit #
No. 79225 Street Laurie Ct.
City La Quinta zip 92253
Tract# 25363-1 Lot # 31 Square Footage
Type of Development Single Family Residence
Comments
By
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.
Y .. .
Fees Paid By cc/Foothill Independent Bank/Topaz Associates T elephon,e Y
Name on the check
y
r
Dolores A. Ballesteros
Superintendent 7 f
Fee collected /exempted by Pauline Pearson Payment Received
Check No
Signaturek
a l� , 4 Ai.A&&-y—
$2,512.92
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