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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
77%%�141 ;3 lO 31.i99
�� �7��
✓Date zignature of ContraEfor _
OWNER -BUILDER DECLARATI N
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.
ZENITH TICS. Cc �. Z,042056902
(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 theiKrk,
rs' compensation provisions of Section 3700 of the Labor
Code all foh comply with those,pr ons
„aate� Applicant
Warning: Failure to secure Workers' Compensatior)fc verage 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 inspectiorf purposes.
ignature (Owner/Agent) " Date - ��
1
BUILDING PERMIT PERMIT# CONTROL!
�13d3 l�i
DATE VALUATION LOT i.'+ TRACT ;��hi� f :.V::
$811.431y�q/ /�y(
JOB SITE
APN
ADDRESS 77-090 D SERI Sl l ll EAki D IVE
g� r��f� DESERT
. ti"373440
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CENTURY CRONVELI.. C;C)i1VaAJN1'; IES
CENTURY C:R,OWELL COIMI tUNInES
1535 SO, "i3" STRE- 1, STE. 02100
1535 SC). na, S'[ It . rr, SCE. 92130
SAN BE-RNARDINO CA 92408
SAN BERNARDINO CA 92408
-
(9050381-6007 CBLf# 21-10
USE OF PERMIT
SPI)
PLAN 2A. -SP -0 '- DEL REY AT 1.A QUiN t A NOZ.'i`S -?1-75 PLAN CHECK
RHOUCT(ON APPLIRD
TRAC'P Ct)N$7'R1Ji; f 1010 1,245,00 S!?
PGRC'i�bPAT10 36.00 SF
GARAGE/CARPOWr 630.00 9F
ElS'E°:[MATED Ct>ti9'r tat+ CONSTRUCTION
80,430.3010
PERMIT FEE S%�14.MARY'
PLAN C1' ECK F1 E 101000-439-318 $463.53
CONSTRUCTfON FEE 10.1-000-418-000 S554.00
MECHANICAL FFS 101-000-421-000 $47.00
ELECTRICAL FIX X 101-000-120-000 SP4.0
MUNIBINO C7:: '.- .,..101-000-419-000 $118.00
S'1'RUNt NtarIONFEE -.R1�SID X401-000-211-000 $8.04
GRADING kTX till -000-123-000 $211,0 i
INFr"STRUC' URE HE 225-000-443-3Ei2 $.1.798.91
PLAK CHECK .F03 � 101 -M -X139-118 41174:1
3
-_: sua-TOTAL COI�s'rRucnON AND PLAN CHECK
$3,114..16
LESS PR E -RAID FE'1's
-$341'1,64
J U L 2 3 l�� 3 TUTAL PERMIT FEES DUE, NOW
$2,766.52
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
y4 .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs 4 el Llool T7 Underground Ducts
Forms & Footings Ducts
Slab Grade =- Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K. to Wrap — O F.A.U.
Framing Compressor
Insulation %z� e Y 1 _ Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
_
Exterior Lath Z -i f YFf
Drywall - Int. Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain,
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Gas Piping'
PLUMBING APPRQVALS 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 Connectionp • j_ Encapsulation
_
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
r C:
Final -
Utility Notice (Perm) ��/ 1
Notice:
Document Cannot Be Duplicated
Date 7/22/98
No. 17371
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN # 604-373-010
Jurisdiction La Quinta
Owner NameCentury Crowell Communities Permit #
No. 79-090 Street Desert Stream Drive
City La Quinta zip 92253
Tract #
Lot #
Type of Development Single Family Residence
Comments
Log #
Study Area
Square Footage 1,245
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
1.93 X 1,245 or $ 2,402.85 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project lriay now,�be issued
Fees Paid By CC/Foothill Independent Bank/Ed Knight Telephone � =
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green
Signature
Payment Received $2,402.85
Check No. 604539
:E: Pursuant of A*mbly 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 I
will begin to run f m 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
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