9604-082 (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
714189 013 1 i9 7
Dated Signature of Contractor
OWNER-BUILDEWDECLAR/�TION
I hereby affirm under penalty of perjurythat l 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
( ) 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 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:
CarrierPolicy No.
1.1:IvI't1! .fl'�:">. 00.:,:t�t:�+tl;�!!+:►!
(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 provisions!' '
`Date: t� �' f Applicant—
Warning:
��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crimi al peneltles 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 property for ins�pectii purposev
,Signature (Owner/Agent) � �"" Date����
BUILDING w PERMIT PERMITk CONTROL# �i
�1�Y�-fix 3 1 6 V '
+VALUATION
DATE '4/18/96 S'� .474.10 LOT 20 TRACT.�;-�
JOB SITE
ADDRESS 79-240LAUMIt, CO CRT
APN
'604-343401
OWNER
CONTRACTOR / DESIGNER / ENGINEER
wixxJ iju'v" CRO%l'ti1.t, CLimmiJNutf
t:ks".!°;`f,'R v crzowfu.f. r1p. fi!'iUNC'tuis
1535 SO, ".O" Siltt:w 1; Ci'f:. Y200
1535 So, "o, grReel" S7'1:. 0200
SAN BERNAti.OW, CA 92409
SAN BERNAfif; INO CA 92409
(4,,))n f -t'i00?
• (!)ti pA 1-64!07 CRI114
USE OF PERMIT
SfNOLR, FAMILY .DW!74.L1N r
,i,15fa 1yAS.'A:W) AVE.
LAA, RfW C� LA QLRNFA LV4` W11i
VI AN VCR
'i'ttxaf, CQJN3TK1.IC'I'K)N L,Cj(>.iol SF
PA4RiAOR/CARPOR't' 417.(11) SF
`!'INVITE(,` 1) (:+13.vT' 0 000, :3'.FRuC
99.47440
PIP RINII IT Fl E, NUNiMARV 1
34E,AY4C1IrrK, Vti R,
Lf-F+t;3 kttC;t1l.'f��:1=' i.all4)(10riZU (N)Zi sit. S
d ,itRf}�ifit3 Ni i?, If)i$10104
M; '01-4tr; 141C)'f'ON 11B 10,'310 1014 ft -241
(AtAW140 F-1111 101 -NO -`1414-000
1NFR&S�rRtJC7,rtTKE NES 22s-000-443-342 VZ20A7
SUB-11VIAL CONMUMION AND PLAN CRECK.
.$3,73t').23
-----;,-- , x LESS PRE -PAID FT ES
$0,00
PYLAV. 3 E>!tf►Iff "IES VUE, NOW
5:3.734,23
APR 2 3 1996-
t pit
RECEIPT... �..�
DATE--,�...�
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings ZV
Ducts
Slab Grade 7 15t Al
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 Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APOROVALS
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 APPR 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
Final
UU14 Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke ()electors
Temp. Use of Power
Final 0A, IYe
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 APN # 604-343-001
No 14347 Jurisdiction La Quinta
Owner Name Century Crowell Communities
No. 79240 Street Laurie Ct.
City La Quinta zip 92253
Tract it 25363-1 Lot # 20 Square Footage
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area 230
1663
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 1,663 or $ 2,860.36
the property listed above and that building permits and/or Certificates of 0ccupar.cy 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. BallesterostM- J
Superintendent
Fee collected /eiempted by Pauline Pearson Payment Received $2,860.36
Check No. 24015
Signature
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
iO Embossed Original- Building Dept:/Applicant Copy - Applicant/Receipt Copy - Accounting