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9511-137 (SFD)LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with C,4 W Section 7000) of Division 3 of the Business and Professionals Code, and my d LO License is in full force and effect. 314473 a 1131/9ti r� W License # Lic. Class Exp. Date r -- Z Date Signatureof Contractor cro H o> OWNER -BUILDER DECLARATION J W 1 hereby affirm that I am exempt from the Contractor's License Law for the CL 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). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044Business & P�esenals Code). � () I am exempt un 9r ature n�B& �i53te on Cf)Date Si nature of Owner N OU rn . WORKER'S COMPENSATIO ECLARATION a. Q I hereby affirm under penalty of perjury en"e of the following declarations: 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers' Hcompensation, as provided for' by Section 3700 of the Labor Code, for the O W 0 performance of the work for which this permit is issued. LL D J J ( ) I have and will maintain workers' compensation insurance, as required by n Q U Section 3700 of the Labor Code, for the performance of the work for which this U permit is issued. My workers' compensation insurance carrier & policy no. are: L Lo Carrier Policy No. ? _Z (This sect�o�need�cLt;bg completed if the permit valuatio%is,1gr�$�O0.00 or less). � () I certify that in the performance of the work for which this permit is issued, C7 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'l;s—Rould become subject to the workers' compensation provisions ofeSection 3700 of the Labor— Code, I -shall forthwith comply with.thosee pr vlsl ns Date: 5,1. Applicant �. r""f .✓� Warning: Failure to secure Workeris�Co�npponsaalio coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a exult of this application agrees to, & shall, indemnify & hold harmless the Cb/of Tari W.611rs its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City tp.gnter.upon the • above-mentioned property for inspection purposes. Signature (Owner/Agent) Date1�( 1 f AL`" BUILDING PERMIT PERW'4,11-111.7 I DATE A. 1!". VALUATION N9 ,fI ." LOT 5 TRAC ZOLM, JOB SITE ADDRESS 74-185 DANE DRIVE: APN 604-312.007 I OWNER CONTRACTOR CEAPI m,Y H©ws doN,,tMuN..nt CENIMY HOMES CO& 11MMES 1535 SOiJTI-1 D STREET #200 1535 SCU114 D STREET #200 SAN jBrx1RN11.1tI3i1No CA 92408 SAN 1313R14ARRDIN, CA 92408 (4109)381-6007 C>311# 2.120 (909)_481-6007 DESIGNER/ENGINEER USE OFPERNBING1,E FAMILY DWELLING O.klf RHY• (.cA I,A 0,411 i rv'°f.A)``Caft7'E PLAN 39 FEE DESCRIPTION FEES'' TRACT C ONMUCTION 1,61&00 SIS GARA.0WCARPORT 417,00 SF F,$TiiW%'fED CWT OF CChNS T RU(7[ON 96.030.60 PERAWF F J.E. SU`M MARY FEE DEPO Irr-S�SO.ilO .1` LAPd CHECK r,1t36 101-000-439-318 $5.28.08 CONS'1'kLIMON M, ' 101-000418-000 $626.1 NIEC:HA:NIGAL FEE 10,14)00-42.1-000 555, 0 FI,i t I'rYiC�17,@ fE 1fli-!?()0-429�00f1 612RA7 FliTfc1I31Nt1 PEE J01-000419-000 138.00, STONG• MO.t ION.1TE - RESID 100-00ti-24.-000 $9.60 GI2AOINO F'EM 101-000-4.23-400 $20.00 1Nt7R4STRt1C,'1 ME FR 215-000-443-742 $7,160A9 SUR= TOTAL CONS'1l2.IX-710N AND PLAN CHECK $3;666.14 LESS PRC -PAID FEES -$250.00 TOTAL PERMff FEES DUE N01V 53,416.14 TOTAI, PROJECT .€ ERMIT FEES 9,6 6.%4 1995 RECEIPT �- DATE By DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS = MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings L Ducts Slab Grade Return Air Steel Combustion Air ' Roof Deck yy Exhaust Fans O.K. to Wrap _ F.A.U. Framing�zw Insulation Compressor Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation2Ti !j Condensate Lines Party Wall Firewall f f 11 t Exterior Lath Electric Final Waste Lines Drvwall - Int. Lath . Water Piping Final Final POOLS - SPAS BLOCKWALL P ROVALS 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 Cover 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. 13912 Desert Sands Unified School District 82-879 Highway 111 Indio, CA 92201 619-775-3500 CERTIFICATE OF COMPLIANCE APN # 604-312-007 Jurisdiction La Quinta Owner Name Century Homes Communities No. 79185 _ Street- Diane Dr. city La Quinta zip 92253 Tract # 26188 Type of Development Comments Lot # 15 Single Family Residence 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. �Telepeone, Name on the check By Dolores A. Ballesteros Superintendent Fee collected /exempted by Pauline Pearson Payment Received X2;408.00 Signature &,9" , .Af,t XL_�,, 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