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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
Date �'���� Signature of Contractor�R,:'^ ,-
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 Policy No.
UN'Ii.`ARE IMTO ANC
(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: 4 / Applicantf".-
Warn ng: 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 p rposes.
,f Signature (Owner/Agentj�1���°P'.i�'C'r^
PERMIT# CONTROL#
• • BUILDING PERMIT 2924
DATE VALUATION LOT 9603-042 TRACT
3/13/96 $124.691.40 (Y. 239,35-6
JOB SITE
ADDRESS
APN
1 45-J4 DES � RT A.1R i3:MVE
6ii4-33 W1
'OWNER
CONTRACTOR / DESIGNER / ENGINEER
1535150. STH,11200
15-15 90. "D" $fkE13-M. SEC. #200
SAN HERNrtEi.DIN, CA, 91409
f3RRN'A'RIANO Cry. 92468
_6007
(909)) 1-6001 Cf.11,1 '41120
USE OF PERMIT
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PLAN 51M
TRACT CON S'TRIJC NON 2,073.00 S
POf2CWPATSO % 63..00 W
GA'RA,Z1FJC,'.ARPt'�RT 576.00 ft<'
r YIT17V TEI D. CI OST OF COisf:STRCICUON
124,691.40
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8UB-"t'U' AL (A, 3i5iVi RUCTION AND PLAN CHECK
`J• ."� �<9iu1187��R 3.riPa.rj OVE leON"
$4,601.24
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
SteelCombustion
Air
Root Deck
Exhaust Fans
O.K to Wrap (O
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
BLOCKWALL APPROVALS
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 AP 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)
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:
Notice:
Document Cannot Be Duplicated
Date 3/12/96
No. 14225
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Homes Communities
No. 45390 Street Desert Air Dr.
City La Quinta
Tract # 23935-6
Type of Development
Comments
Lot # 6
Single Family Residence
APN # 604-332-001
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area 228
Square Footage 2073
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 2,073 or $3,565.56
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. 'E
}_
_ Fees Paid By Century Homes -Topaz Associates LP - Telephone '
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,565.56
Signature A1C .t\,Rfu ^ �,p/✓�
Check No. 102154
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