9803-116 (SFD)I61
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.
(AI 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.
ZE'•1 TITH INS. CO. 2042066902
(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 t?/he workers' compensation prove ions of 9ction 3700 of the Labor
Code�� 1 f t� '�ith comply with�those, rovlsiQas
�Date:-f� Applicant—
Warning: ,.
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. i
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 r presentatives of this City to enter upon,
the above-mentioned property fQr i , pecti n purp ses.
uSignature (Owner/Agent) f Date
BUILDING PERMIT PERMIT #`y CONTROL#
DATE VALUATION LOTa�-j''�� TRACT
815147 9
$911,909.50 31
JOB SITE
APN
ADDRESS -
79-070 DESjERT STRrAM DRIVE .
6(W373-011
OWNER —
CONTRACTOR/DESIGNER/ENGINEER
i'EN1TL,rRY CRO%,'FLL COm1VitTNL fi S
C.EP 1'URY CRO tirEi L C OM:AitJNTTI1ES
1535 SO. "10" STREET, STE. 0200
1535 SO, "D'' STREET, ST .AGOG.
SAN BERNAR DINO CA .912408
SAN BE1t NARDINO CA 92408
r!xOJ}381-600? CBLi>E 2.120
USE OF PERMIT
PLAN 3CR - SFD - DFL. RLs'Y AT LA. QT~'0 ,,.A. NORTE -'la7j PLAN CUMCK
REDUCTION APPLIIYD
TRACT CONSTRUCt` Off 1,445.00 SF
GARAGWICARPORT 635.00 V
s
ESTIMATED COST OF CONSTRUCTION
941,S►d19.�o
PERMIT F'CE SUMMARY
PLAN CMCK FEE 101-000,439-318 $504.98
CONST.KVC`1T1ON FEE 101-0004.1.8-;100 $599.00
i�fECsiANICAt: I?FE f Q 1-tz®o-421-000 U7.00
Et,FCMCAL FFE 101-000-420-000 $11:1.78
PLUNI13M FES 101 -MO -419-000 $148.00
STROC NO MOTION 1:`E, - RESID 101-000-241-000 $9.09
GRADING FEE 101-000-423-M S20,00
[NFRA, S7R,UCTUIZE FK- ^-25-000-443-342 $2,045.A6
PLAN CHECK FEE 101.-0110 439-318 -$378.73
w.
�-� ,S(IB=I��Tlli. �.'ONS'F't�C.1G'i'lt�N AND MAN 1~:%11•C'1:.
S3> 4$x.31.
LESS 1'RE-PAID:i EEk
-'3
4378.73
TOTAL PE.RMIT ) rfri 51DUE Now
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
r
Return Air
Steel
Combustion Air
Roof Deck
!_(— —Q
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
2—
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls"
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/z—/6-
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVAILS
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 APPROVALS
Gas Test
Electric Final
Waste Lines
7 — l ry — 9-g-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
.� 3=�i�
Encapsulation
Gas Test
Appliances
Final
Final
Utility 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 Detectors
Temp. Use of Power 9
E
Final
Utility Notice (Perm) f'y
COMMENTS:
Desert Sands Unified School District
47-950 Dune Palms Road '
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 7/22/98 APN # 604-373-011
No. 17372 Jurisdiction La Quinta
Owner NameCentury Crowell Communities Permit #
No. 79-070 Street Desert Stream Drive Log #
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 1,445
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
1.93 X 1,445 or $ 2,788.85 the property listed above and that buildi- g.'
permits and/or Certificates of Occupancy for this square footage in this proposed project.fday now, be issued
Fees Paid By CC/Foothill Independent Bank/Ed Knight Telephone',
Name on the check
1
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green
Signature
Payment Received $2,788.85
Check No. 604539
NOTICE: Pursuant of Asmbly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run fr the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
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