9603-052 (SFD)I�
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 # rL�ic. Class Exp. Date
i 1, i-rSil >:y 4Jl6� r i
Date Signature of Contractor d
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).
O 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 uN1t ll1 1Ni,q1U72A.N0, Policy No.. U15,0105-09
(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 Lab r�
Code, I shall forthwith comply with those provisions.
Date: "' /re., f Applicant ��ar p -,e' w..;�'` ✓d.- :
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 'bn 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 fo fins , ectio?pff/rposes. f
Signature (Owner/Agent) u Date
BUILDING PERMIT PERMIT# CONTROL#
2937
DATE VALUATION 5123,914`71 LOT'- ( TRACTS()
AOB SITE
DDRESS .RWillsi.. i
APN
• OWNER
CONTRACTOR/DESIGNER/ENGINEER
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NAN 8PINARDIN, C:A, 92408
SAK 1-.iERN.A.Rz DIN0 * CA 92408
0001,19t-6007.
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USE OF PERMIT
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i4lLCIiANICAL FEF 101-000-421-000 09.00
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,1i4,57l 95
LESS PRE -PAID FM
10.00
'�j U l:'AL 1'8�:t{11UT J?F_ 1��rt� 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 V IXX
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap r
F.A.U.
Framing Z
Compressor
Insulation + /
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
17-
Final
Final -
BLOCKWALUAP'OhOVALS
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 APR VALS
Gas Test
Electric Final
Waste Lines09
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral 1
Pool Cover
Sewer Connection (06
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) -147zZO 07
ELECTRICAL PP OVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 3/12/96
No. 14235
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Jurisdiction
Owner Name Century Homes Communities
No. 79320 Street Desert Wind Ct.
City La Quinta zip 92253
APN # 604-332-011
La Quinta
Permit #
Log #
Study Area 228
Tract # 23935-6 Lot # 16 Square Footage 2121
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 2,121 or $3,648.12
the property listed above and that building permits and/or Certificates of Occiipncy,for
this square footage in this proposed project may now be issued.
Fees Paid By Century Homes -Topaz Associates LP Telephone '
Name on the check
By Dolores A. Ballesteros
;=
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,648.12
Check No. 102154
Signature x I Q I AA -Q Al A tAN\
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