9603-053 (SFD)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
7141V 13 top 1.19 i
j ..s
Date A1- t!< Signature of Contractors
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.
( ) 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 TWICA12ji.tN:iURANO Policy No. ��ya-i?3 5 tYS►
(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 Section 3700 of the Labor
Code, I shall forthwith comply with those pr
pyisions./�� %
Date: Applicant. J� m.r t�.,•nr.�.f.,� + •�:G�.EC" .
Warning: Failure to secure Workers' Compensation coverage'is unlawful and
shall subject an employer to criminal penalties and civil fines up. to $100;000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safefy
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspections gurposes.
Signature (Owner/Agent)-; �, .-f "// Dat&:!Z✓'" l
BUILDING PERMIT PERMIT# °°NTR°`"
,x.053 2.938
DATE 3.113196 VALUATION ��.i!¢f��li. � LOT17 TRA�CT935_6
JOB SITE D,DRESS -79-310i�p'«��1,F�T .�iN.�D CCi�JI�T
APN QIt�$ .�.i��i-�I12
'OWNER
CONTRACTOR / DESIGNER / ENGINEER
1533 SO; V* gntFEV, SUE 4.200
1535 SO. #1)" STR1; ET, S-fE. h200
SAN 13ERNA1Z1 IN CA 92408
SAN f3ri- :N.AR.D. NO CA 92408
(909)234;I<6007
(909)381-6007 G131JI 71'N .
33M17AWN AG LATt & ASSOCTA7
USE OF PERMIT
SINGLE FAMILY DWELLING
_159 PASSNMO AVE.' ,
• r.�e,?t .�k;, 4 �t)a
TOPAZ @ LA. Qili.NT A NOR,'IT-,
i
'i ttf3tl'I' CUNS'!'#3t3 "TTC�:N 2073.00 S
`r
i
P0R<.`f 1PAT10 63.00 S1:'
OARAGWCARPOItT .576.00 SH'
R l'i.iY.wTED COST OF CONSTRUCTION
U4.��� afs
'It'i�;R;l1�:�'1' 1♦1��> �LfR�16fiA3t�' .
PLAN c,ME K t�Z1 101-000-439-318
C ONS't'J.2UU1710N FM11 101-000.41.5••001). ST.17.00
9 .tau
iL•.11i0#U'N Cf,A1, r- C6 1171.400-421-000Co
ks .EL" t iifr'AI i' 101.40,420-(t(K1 X 13".513
a
P1;slf�f�ti�i?� .. �. 3[11,-Ot1h.a{�.Cit10 �1.6�2g
�-
't ,fiv,*r ioN'r F t _' RUSID 101-000-241-0L10
ClltAfr�ta'ar.t�%k. : , ic}i..hi0�423-iris �2t).uQ
( �
3Cdt Ei_Asst E`1tt SP; t'�!i21.:1' f1i 2254VOA l3-212 $7.,7t#Ei.7U
al Q
hRi"►f3.1tTltl,11;!;9. ACTS -}2t;hi1:7fi-()#it?^5S-
SUH-TOTAL CONSTItUC"t'ICIN AND PLAN CHECK K
$4,601.2-1
USS PRE -PAW FEES
$0,00
7f77.wL.. , PP., t'1�gA.f'!.• S`il�iA al ZlreNo'Yf
,3'4oT3sJ3:2Y
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 tfloy
Return Air
Steel
Combustion Air
Roof Deck
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 /1
Drywall - Int. Lath 6
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location'
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPR VALS
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 6
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
..
Final
Utility Notice (Gas)
ELECTRICAL P ROVALS
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)
Notice:
Document Cannot Be Duplicated
Date 3/12/96
No. 14236
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Homes Communities
No. 79310
City La Quinta
Tract # 23935-6
Street Desert Wind Ct.
Lot # 17
Jurisdiction
zip 92253
APN # 604-332-012
La Quinta
Permit #
Log #
Study Area 228
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 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 1.72 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.
Fees Paid By Century Homes -Topaz Associates LP Tels7 hone
Name on the check '
By Dolores A. Ballesteros t `
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,565.56
SignatureL!!= a Al AA Wv—
, Check No.
102154
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