9604-095 (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
�rf
Date r � _ Signature of Contracto�rf Z
OWNER-BUILDER;DECLARATION
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).
() 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 /'fjt41I11 lNtA,, t ew!. Policy No.
(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 1 should become
subject to the workers' compensation proA68 s of Sectio_n.3700 of the Labor
Code, I shall forthwith comply with those', provisions. '
Date: Applicant
Warning: Failure to secure Wore' Compensation coverage is unlawful and
shall subject an employer to crmir4l 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 State1dws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for'inspection: pu�p'oses.
Signature (Owner/Agent/r• Date�/_o
BUILDING PERMIT
DATE 411 9M, VALUATION 07 90,5 o*1) LOT
PERMIT # CONTROL #
3181
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CONTRACTOR/DESIGNER/ENGINEER
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APR 2 3 1996-
RECEIPT £ DATE B.Y DATE FINALED INSPECTOR
1+3,3-i1.!6
WOO
53;341. 16
i
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 7 f
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL P 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 APR VALS
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
Utility Notice (Gas) i
ELECTRICAL APOROVALS
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:
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 # 604-343-014
No. 14361 Jurisdiction La Quints
Owner Name Century Crowell Communities .
No 79245 Street Laurie Ct.
City La Quinta
Tract # 25363-1
Type of Development
Comments
By
zip 92253
Lot # 33 Square Footage
Single Family Residence
Permit #
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 bcc.'u' for
this square footage in this proposed project may now be issued.
V _
Fees Paid By cc/Foothill Independent Bank/Topaz Associates-:gTeleN one;3
Name on the check
Dolores A. Ballesteros r
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $2,512.92
Check No. 24015
Signature � '
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
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