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LICENSED CONTRACT013 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
Al 188
Date,Signature of Contractor'
r
TOWNER -BUILDER CL ATICN14
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). ' •� a r1
() I am exempt -under Section B&P.C.f for this reason
Date Signature of Owner
�l
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of, perjury one of, the following declarations:
( ) I have and will maintain a certificate of conserit to self -insure for workers'
compensation, as provided for16y 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 bye
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 VTNI' I ((.J8, >l;aj. 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: -f-2" /X /'Applicant
Warning: Failure to secure Workers Compensation "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 property for inspection purposes.
Signature (Owner/Agent) Date f ' `
BUILDING PERMIT PERMIT# °°NT3
St61).��.�i9 3 3
DATE ` VALUATION 5i 16,3f;Q.10 LOT. 2 TRA&,0.1S.(s 6'1{i4
JOB
ADDRESS 4.? -2.7i DRSElR MRV RAST
APN
i1 3. -1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
H.1 IJ1IJRY 01110" T:tt,;1.. COMA1Uivrii P
CE`71T„tiYCRfl,N"I C 0 X I N IINi'r.es;
ISIS SO. "i3" 51Tt1sF 1', i 1:. bx,t7i7
,
1335 SO. "13" S7.'REEP, ;'M #200
SAN BERNA1tDW (;;A 92,109
SAN HERNAlt' ANO CA 142409
• (�1(k1�3H1-tii}a7
{���';F31-f�i?Q7 �'�tl.� :a2q
HE"10AMW AGUI AR rh_SS'0i . Rq . .
USE OF PERMIT
MOLE FAMILY DWELLING
5459 P.A lSURO AAV'F. -
-` � � ,•
' 1'13 V M,11i.9 K11 �,. t\ uL t y'
1•C.11AZ Ax LA QVIt 'rA tds?32TI? �>
PLAN 4AL'1"4, '
68.00 3F
OAl2.A.(W- CARPORT 4.18.00 1%
1��53'Iv€.�IED Clod OF C:ONSTRUC:`N
PERMIT FEE tig11iIJS+r; ARV
I31,AN Ct-RTX FFY
C_OINS1111:L 11ION I t11 101-OW418-000 so".00
it':xiCii"i.C;/AL fl-1iE 101-cw-421-000 S19,11,10
Is3,H( t"UCAJ,'FEE 101-000.420-M 3fv?.17
PP.S.a1,IRINO TV 10► -t X119-i)t X167.:5
STC1"N 1 1MCGI N r1ii."s - Ii[i,310 101.-000-2.11-000 $11.64
OkA1)jW t;*ItLi 10-0)-423.01XI $20.46
INI.R.A.SIVeOG-ftlKf.22544-4143-342 s2v.597.5:,%
ART IN I'fJ01,Ir: t'LACT-ES • RES11: 701 -(XV -255.0.00
1�7E•'IY7"E'r' b CONSTRL3f:.'1'1ON AND PLAN C1•I.Et:;X;
U1 LESS PRE A117 FE.t S
$600
-P
JUi ,
tl
%V - A1. PERMITFEES 1113E NOW'
ey G
"
$4,335;
r_
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings -
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Root 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 Wall Firewall "
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL XPPFi6VALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROV LS
Gas Test
Electric Final
Waste Lines 044Heater
Final
Water Piping
Plumbing Final
Plumbing Top Out.
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection v1 144Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
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
t•
Date 6/3/96 APN #
No. 14532 Jurisdiction La Quinta
Owner Name Century Crowell Communities
No 45275
City La Quinta.
Tract # 23935-6
Street Desert Air St
Lot # 2
604-331-004
Permit #
Log #
Zip 92260 Study Area 232
Square Footage 1903
Type of Development Single Family Residence No. 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 1.84 x 1,903 or $ 3,501.52
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 Century Crowell Communities
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Telephone .
Payment Received $3,501.52
Check No. 103483/103523
Signature D A , r,�� �y &A N A--Y%.-
Collector:
YLCollector: 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