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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
ate fv Signature of Contr ctor
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.
(y) 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.
17w.i. lrw. -r..l r.;s• Rtu+n
4AL01l.tit
(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 the workers' compensatiojr-prov' . of S� ion 3700 of the Labor
Cy �de�I hall-foAtf• m comply with�thos rovisi • n ,/
+Date. �— Applican � - ' `
Warning: Failure to secure Workers' Compere ati' n 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 tor_
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 pro ert%f rIhspectiurposes.
,,Signature (Owner/Ag nt), Date
f �
PERMIT #
BUILDING PERMIT
gx101.1114
DATE 7/23J+N VALUATION �� 1t17fi7,4f) LOT �,1 TRACT ' 7R+113
ADDRESS 1.1-11111)(!..111111!1{l1f:J�lYiU1ZfL�X. 7�__#,
Ni°•.S/J-M1�1`i
OWNER
CONTRACTOR / DESIGNER / ENGINEER
7 rl:twi'1 lir %r r''/W%v,7r;F i or"%& 11;41 1Ki1'i'I tS G;
iI t'Ni')'11lj i* 0"4"'st1r171 1 '04, ib i.ldI JTirl,tf:C1
,.4 i A...•A, i Wi\V tl• L.,,IAl'IirY.l•11 1 ./t.i1
.-. i.,'t I IJAi. r L. rtiJ V1 4,i.s4. \.-.,,. iM1 l/{,l 1144. li.w
! :33 St). "1)'''SN'P1EM, Ci'1:. ON
so. .13- ,1;t€.. #20r,
SAN BlikNARIANO CA. 92409
SAN URI+JARIANO CA, 92408
r�3tlyl�ttf-i;fN17 <;�t.�f nl�f>;
USE OF PERMIT
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(Y' )NNTRI.it;NON HF)i i0t-0110-4.1[8.000
IIV.A'N 0lr,(% '1 VP V.146 ss
1'kY3X3iA?;11ivw 101 ow 1 1.000 V7,00
l;i.lirW 1. -EH . 101-()00 42_0.OW V26.0.'P3
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i* U.i��N1NO FEE !t)a-f?I►f3 +3iq-Uv $172.011
1;,r �tiN0 HCrf )� 4 t.,f - REST)
!� #�11-t1(}li yd!-flfl(i $t1,HR
Ol<11i.11NU 1:8L 101-000-12,34K10 �kstJ.tfO
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AWVIN P(4113C PI.Ar,338 - IZt N1G 7m 4f.? .1,5'5-000 V t.42
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V;)'Y,'At.1<'ERNA F F'Ei+% 0111: NOW
S3,892.415
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RECEIPT'
DATE
BY '' v
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &. Footings
Ducts
Slab Grade
l
Return Air
Steel
Combustion Air
Roof Deck
/
Exhaust Fans
O.K. to WrapF.A.U.
Framing
y
Compressor
Insulation
Z (0 4 ✓
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 APPROVAL
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
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
1
Encapsulation
Gas Piping
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility. Notice (Perm)
COMMENTS:
1
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
No. 17370
Owner NameCentury Crowell Communities
No. 79-110 Street Desert Stream Drive
City La Quinta
Tract # Lot #
APN # 604-373-009
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Square Footage 2,010
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. 2,010 or $ 3,879.30 the property listed above and that �build.ing
permits and/or Certificates of Occupancy for this square footage in this proposed project may how be issued
_�
4, Y ,
Fees Paid By CC/Foothill Independent Bank/Ed Knight ` �__Telepho e '
Name on the check r
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by
Signature (:: U
Juanita Green
Payment Received $3,879.30
Check No. 604539
NOTICE: Pursuant of Asbly 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
Im