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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'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I amlexempt 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:
Carver ;j NITH ItvS. CO. Policy No. 2(421(W*90t
(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.agiee 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: 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 l
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 f
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
BUILDING PERMIT PERMIT4WI5451 CONT L3# 4
TRACT iiS
DATE VALUATION $87,174.40 LOT r,f
} fj 111 t3
ADDRESS 7'9-285 D SER'i CREST DRIVE JOB
APN .604-332,016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1535 SO. "W SUEET, S"1'Ci.'f;200
1535 80. 93" S1'FdRKr, STT, 9-200
SAN RERNAIt IN, -CA 92408
SAN BERNARDINO CA. MOR
(90 )!K) -6M)7
(909)1$1-FifiOi CSLN 2320
BENJAMIN
ENJYiMIN ACU AR ASSOC. INC.
USE OF PERMIT
SINGLE. FAMILY DkWiLLING
5459 PASSrERC) AA:V13.
c vrtic'_tt6f A k
A)' I.A Q)UINTA NCgtTii
�TOPAZ
1 y,I,A 2MW ,
TitAOf C ONSTRUC:110N 7,Q43.00 Sly
PORCH/PATIO 95.00 SP
GARAtsFJG'A►tP0Wf 420,00 SF
F„S`ir.711A'F ED COST OF -CONSTRUCTION
87,i 74.44
Ill , n`N (; H (110111, 1 IiTr sdg5 'F7
Cs:3►v" TRU-1'IC32'd Ird•ti l{7 -£300-X31$-0 $5.05-50
NiVCU A.NI<:r'1L t's)J 101-000.421-000 S65.30
i LE(, fkl.CALFEE 10) -1)000.4204)00 S fU7,i)fi;
i?f,f►pilSitNl}.f�'1';i� ifl,lw[ji1(l:�i).i.�(i �)•ill.Et't
""t c. t4c i�is~3•I•tol t 4 2- t�F 3s.1� . 101-t1(m-�'• t.ntiU rs.72
C�1s+rit�{Ivt'y I'i;i{� •101•i�3{'►w)LJ-{1liG 9erlt>.fell
�lNNgtt1,S'i'!il.It°7't1t2.�. f�f:i? 244•()f}()„cta.l3-,i�f2 $.t,4)3� Wt
r
I1�i �Q Sl ffll-1VIA L CONS rltUCTION A1eIJ FLAN C:.IIHC''14
LESS.PRE-PAID FEVS
$3,354.5,11
$0,00
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 t
Return Air
Steel
Combustion Air
Roof Deck T.;
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
.BLOCKWALI P OVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out VEquipment
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral Y142,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APP OVALS
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)
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/3/96
No. 14534
APN # 604-332-016
Jurisdiction La Quinta
Owner Name Century Crowell Communities
No. 79285 Street Desert Crest Dr.
City La Quinta zip 92253
Tract # 23935-6
Lot # 21
Permit #
Log #
Study Area 232
Square Footage 1433
Type of Development Single Family Residence No. of Units 1
Comments
N
By
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 1,433 or $ 2,636.72
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
Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Payment Received
Check No.
SignatureP " Q' /% oe pAA A�C�y�i✓�
Telephone
$2,636.72
103483/103523
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