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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat 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
14189 B
Date'' ~� !- /6, Signature of Contractor �l
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-pne. 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,. fog 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 Uti.iti'AJJji,, fNI,t'sfi/1Nt: Policy No. ia1L��aWy -t}>
(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 Sect'on•3700 of'the Laor,
Code, I shall forthwith comply with those provisions.
Date: r«,,V `r 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
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
%purposes
.
'\Signature (Owner/Agent)'���-'F"�"
BUILDING PERMIT
PERMIT# ' .
°°NTR°`#
.
900".56
2941
DATE %t��a VALUATION$124.61 t.4(i LOT
'10 TRA= i���
JOB SITE �� aLrrttt
ADDRESS 794W� t...�!.Et ��rl!'�a'f COURT
APN
604-331-015;
i
OWNER
CONTRACTOR/DESIGNER ENG�.
!
f.. '�l:,'1. �a1'tY�f.)� �aT p�".•a��i.i'�r �..�... +.: t�i rtau i� a'� '1'n-;�
III�NiEE19R
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t w 35 SO. ' j" .a l` Lti#s'C, "iT . ;�A. I
15_53190► 11D" S"i`.iU18q,
9f E. ? 2100
SAN I-0-* JA.KftN GA. 92ift
SAN
CA.- 92408
� t i11 I•-i�fl(1
f 009)3R 1.007
.1i13PQrsiE IN r',.GUILA.Iv*
C P L,#. 2120
A;i.`'a'U1..l. kl
USE OF PERMIT
,SJN il.h VANJJ1,1' 1.,113 EL.1a1N1J
fS9 wA 3S1':ftC:► AVf:.:
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PLAN 5, A
TRACT Q bi91;1?AJt;1'!QN :e,t)^13.1ti) SI:'
�NO
f*iIMMPATIO) 63XI0 Sri
. _
0ARAO lCARZF'(:)1 C SI'
!"i+S7111M,A'tiCOST OF CONS"1",RAJC'110
124,691.40
9 .?1N (`p'qyi"`.r,K,VFIY;101-200-49-31
.p7�2�47.,0.50.1
FE.C. 101-00&& lly-00i/0i
tQr f I ANJ C F*VL F'FA3 I ff 1-{10E? 421-ijUQ
Jj.t�;a
rn
19.'E ".I'RICAt.FUE.' - i01-00()-420-000
V32.58
lx r -
I'# it�.x�r�lc� tit:i, '}Q41.�td�i1-41��13f�0
�tP7,2.S
iia
�a r�Iao a Pv[C31'iC?N i = ttGS,3� 101 Otto 241. 000 _
$12.47
t�1Lt�l�ls3t.11;l�4 11}.i-t1t)Ci �`?e�-ilii().
�`�Q.t?t)
Q( cr
(1�1i�1 A,ti ('k.[1C:'.I'111 L,4 ala 22.5-000-443-342
$2,7#ttj30
Q
ART !N 1?1f4j,!C PT,A(T.S - ($i�S?►`... i�i-lffli3- "��5-(i(J(9.
61.73
-
L7
0111,:110T AL {:(7NM,7 R. C*1'1Gt - AND PLAN CHECK.
$4,601,24
I,is"5.S PRE -.PAID F ES
`b i.{?#i
1'(.YfAL fl'.Ik:it411ff till CS DUE NOW
�4,GtD1.24
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
Retum Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
FramingCompressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath /
Final
Final
POOLS -SPAS
BLOCKWALL A P OVALS _
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric:
Underground Pibg. Test
Final
Cas Piping
PLUMBING APP O ALS
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
COMMENTS:
Final
Utility Notice (Gas)14 L -
ELECTRICAL A PR VALS
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 3/12/96 APN # 604-332-015
No. 14239 Jurisdiction La Quinta
Owner Name Century Homes Communities Permit #
No. 79280 Street Desert Wind Ct. Log #
City La Quinta zip 92253 Study Area 228
Tract # 23935-6 Lot # 20 Square Footage 2073
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 X00 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 F
a
Fees Paid By Century Homes -Topaz Assocaites LP TelE;;hone
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,565.56
Check No. 102154
Signature 1
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