9511-139 (SFD)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W Section 7000) of Division 3 of the Business and Professionals Code, and my
oCy co License is in full force and effect.
n is V1 s' 6 1/3L'96
I- W W � License #_ Lic. I�s Exp. Date
ZDate Signatureof Contractor
coo 0r`
o) OWNER -BUILDER DECLARATION
J U 1 hereby affirm that I am exempt from the Contractor's License Law for the
W following reason:'
U) () I, as owner • of the property, or my employees with wages as their sole
Z compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
() 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Busi -dss & Profs ssiona�ls"�Code).
O I am4xempt under Section ,130.'b'.for thiprea"sQn
Date , I�11' l; ' Sign_ ature of Owner_`__,ul
•; :+ �' ''~
rn WORKER'S COMPENSATIONr;:E; A
FL pAT10N
Q I hereby affirm under penalty of perjury on�� following declarations:'
C) Z () I have and will maintain s certificate of consent to self -insure for workers'
cc compensation, as provided for 9i Section 3700 of the Labor Code, for the
X W tL performance of the work for which this permit is issued.
p J _J () I have and will maintain workers' compensation insurance, as required by
Cal Q L) Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
? (This section need not be completed if the permit valuation is for $100.00 or less).
() I cei�ifyTtha>^ili�tiierperformance of the work for whichitt�is permit is issued,
O I shall not employ ariy person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I shouldbecome
subject to the workers' compensation provisions of Section 3700 of the Labor
0 Code, I Of forthwith comply with those provisions''
Date: / (_1✓ ° Applicant
Warn(ng: Failure to secure Workers' 6o n !�9n,c"overage is unlawful and shall
subject an employer to criminal penaltlesrand civil fines up to $100,000, in
addition to the cost of compenson ,damages as provided for in Section 3706
of the Labor Code, interest and ney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as akresult of this application agrees to, & shall, indemnify
& hold harmless the 134
-9 ianiVyell3-jts officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
mwgl� work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
• above-mentioned property for inspection=purposes:
.Signature (Owner/Agent)�,,..��� D
A"'
s
. BUILDING PERMIT
PERMIT:
')5.11-139
DATE �¢
VALUATION S38,4"
LOT 17 TRACT 261818
JOB SITE ADDRESS
APN
79-170 DIANE0P_
6"313-11101 '
OWNER
CONTRACTOR
C N' l kY HCAN1~1?bS COM N4L N FI''1r?,S
CEN'1 [1RY HOMES CtINMIUNT1 ES
1535 SOUTH f3 S'TREF.T 4200
1535 SOUTH D STREET #1200
SAt BERNARDINO CA 92408
SAN BERNARDIN, CA 92408
NQM191-6007 CSL# 7120
DESIGNERIENGINEER
(909)381,6007
USE OF PER6U TWINGE, FAMILY DWELLING
DEL REY @,,,, LA. QLAN'TA NOR TIS
PIAN 3CR
FEE DESCRIPTION
FEES
TRACT CONN '.1 UC,11.011 1,400.00 i.F'
GARA(MCARPOV .635.00 SF
ESTTUiIA'1 E D COST OF CONSTRUCTION
4,46&00
1''EX!$T'T FEE SUMMA Y
LAN Ci -1F CIS FM 1.0.1-111}0-439-31$ $499.90
--C ONM i 12IXTiON FIX, 101-000»41. $000 $590.00
Ml?.t. RANICAL FEE 10..1-x}00421-000 $49.00
FLECTl" I AL FEE 101-00(1.420-000 $125,2.0
C! . Cn
P1111"I'i' ?vt'f7lr 1.01-000-419-000
1��lk2Yl�.�'IIDrl1?1-.I;ESIl) 1.03-CCO.24a�i0
GRADI.NGF'W 101-00(1-423.000
IMM S'1RUCIURFFid 225-006-443-342 $1,990.49
l Q
SUP-TCTAL CONIMUCTION AND PLAN CHECK:
x,3,421.44
LESS P.RE-PWD FEES
$0.00
TOTAL PERAUT FUN DUE NOW
Do421.44
TOTAL PROJECT 1?F:1;dMIT FEES
3,421..44
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
Return Air
Steel
Combustion Air
Roof Deck
3
Exhaust Fans
O.K. to Wrap
Q
F.A.U.
Framing
Compressor
Insulation
Z,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation 4Z2Z
Condensate Lines
Party Wall Firewall
Exterior Lath -
09
Drywall - Int. Lath
gieN
Final
FinaliWV
BLOCKWALL
WWJPOOLS
PP OVALS
- 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 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 over
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
Notice:
Document Cannot Be Duplicated
Date 11/28/95
No. 13914
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-313-001
Jurisdiction La Quinta
Owner Name Century Homes Communities
No. 79170- -- Street-- Diane Dr.
City La Quinta zip 92253
Tract # 26188 Lot # 17
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area 232
Square Footage 1400
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 1,400 or $ 2,408.00
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 L.P. Telephone .
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature '�`�A ,x,10 pMM_01�.
Payment Received $2,408.00
Check No. 22479
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