9603-045 (SFD)LICENSED CONTRACTOR DECLARATION .
U) 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
N W Professionals Code, and my License is in full force and effect.
0 ch Licensee 1i. � iic. Class Exp. DateLO
r W
Z r- Date" 11X'Signature of Contractor
�0r-
J V 6 OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ D- License Law for the following reason:
Z_ ( ) 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). ,
co () I am exempt, under, Section B&P.C.for this reason
LO
N Date Signature of Owner
N
Q_ Q WORKER'S COMPENSATION DECLARATION
O2
Z I hereby affirm under. penalty of perjury one of *the following declarations:
F- p () 1 have and will maintain a certificate of consent to self -insure for workers'
X w compensation, as provided for by Section 3700 of the Labor Code, for. the
m_:Q performance of the work for which this permit is issued.
Q U ( ) 1 have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
CC
F<:
permit is issued My workers' compensation insurance carrier„&. policy no. are:
Z Carrier (01IC/�.tc.#a C.NSUr A&U. Policy No. �iA2a-U Wa t-
cob 5
C)
J (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
3" Code, I shall forthwith comply with those provisions.
/Date: �a. , r.:. !"i!. Applicant •-L4.-t-, --
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. r
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)'-. " 1* J� Dated
BUILDINGPERMIT
DATEVALUATION �df' LOT
JOB SITE
ADDRESS
OWNER
C:HMIURY Cta.OW111101 COMMUNITR-;
1535 so. 11t,1" ti.MMI' STEI.4200
SA1V 813
14NA1'ti IN, Cts 92408
(909)381-6007
USE OF PERMIT
S1NOU, Pt1MI WELLING
i
T+apAf 1`6_,, LA QVINPA. l 0Xn_
PLAWINAR
TR.A1.'.T CONSTRUG110N
P01ZCI4/PAT(0
0ARAMCAPWO'R f
PERMIT,# ,,,04j CONTROL#
Jb TRACT 1935-6 2930
APN
CONTRACTOR/DESIGNER/ENGINEER
CEN3 URY CROWELL ::Cml4fUmn Ess
1.555 SO. ".13" S i"BEET, Slt. 6200
SAN NERNARDWO' CA 92403
(909)381-6007 C",1IX 2120
54e9 PAS ER.0 Mri ,, .
2,07-1.00 Sly
63.00 S1:
576.00 -SX.
r-
PS"!'iMM'" D COST OF CONS'iRBJC1t'4ON
:124.691.40
:!'RRM T '1%l�: SZ7i1!li11Ai1;'�
PLAN Ci;CIiCX:1r'1•s93
.101-000-139-318—
C: �t �t'RtLrrc�ia s
101-000-418-0000
$727,00
l�i>CihiliiAi:1'1E
lt�,l-0Ci0-4d.1-(JOfi
�73.��t)
C.0
i'LEC1111111CAa �N�_
"101-000-420.000
rn
1•'1 � f Ag�;1N�:� 1;`FF'
1111 �()L1Q>4 i � �jfl(5
g i f,'7,`,! 4
a )Iv"C 1bft)110td.1. t 1 . Rr,'51P
101-WO,24.1-0110
MA 77
�+
O1d.AtiD1`M0 FUH,
101-000-47 k)00
$20,00
1t 11'6 t� l[tf.le�`1tii2i? f�J.
125-0011-443-342
92,7iOXI
Q �
Q
A.1?'1' i3d i9Kf4�9.ii` E'1,t><at-s+3 - fa7a''t1,f , 7f11.!'iiNt-2S'S-f1�J11
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St111=101'.AL CON1,1't.1:.t1t,'°C ONAND .PLAN Cif E'CK I �f 01.14
LESS PRE-PAIDFE.9,S $0.00
DATE I BY I DATE FINALED [ INSPECTOR
$0,.401.24
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel .
"Combustion Air
Roof Deck
Exhaust Fans
Ox to Wrap i
F.A.U.
Framing
Compressor
InsulationAir
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation :
Condensate Lines
Party Wall Firewall
Exterior Lath r
Drywall - Int. LathI 7b
d
Final
Final'
POOLS - SPAS
BLOCK LL PPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
? ;;
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING AP, P ALS
Gas Test
Electric Final
Waste Lines
Neater 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
I
Appliances
Final
COMMENTS:
w'
I }
}
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
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
No. 14228
Owner Name Century Homes Communities
No. 79325
City La Quinta
Tract # 23935-6
Type of Development
Comments
Street Desert Wind Ct.
Lot # 9
Single Family Residence
APN #
Jurisdiction La Quinta
604-332-004
Permit #
Log #
Zip 92253 Study Area 228
Square Footage 2073
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 1.72 X 2,073 or $ 3,565.56
the property listed above and that building permits and/or Certificates of 0:e'c4�aricy far
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 $3,565.56
Signature I Pcl�kkl 09AAJ \ <•
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