9511-141 (SFD)(n LICENSED CONTRACTOR DECLARATION
F- I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
C,JW Section 7000) of Division 3 of the Business and Professionals Code, and my
r O co License is in full force and effect. 314473 B il. v-
r� W License # / Lic. Class -.• Exp ate/
Date iAp `r. FSignature ofContracto,..A ..�"
Z
P OWNER -BUILDER DECa ON
J W 1 hereby affirm that I am exempt from the Contractors License Law for the
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 propee am exclusively contracting with licensed
contractors to construct the poF"ject (Sec. 7044, Business & Professionals Code).
( ) I am exempt.urider Section- B&P.C. for this reason `
M Date Sig natur6 of Owner
LO
N
O rn WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
C) M Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo H O compensation, as provided. for by Section 3700 of the Labor Code, for the
X W W performance of the work for which this permit is issued.
O J J ( ) I have and will maintain workers' compensation insurance, as required by
coQ U 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:
CL U') Carrier Policy No.
'T Z (This section need not be ompleted if the permit valuation.is forr$100.00 or less).
() I ceNrtify(t��ainherformance 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 shodrd become
subject to the workers' compensation provisions of Section00 of the Labor✓
0 a Code, I shall forthwith comply with those provisions.
Date: '&/,G4t-- Applicaannt�
Warning: Failure to securetWor ers' Comiss
. n coverage is unlawful and shall
subject an employer to crim,es� pp and civil fines up to $100,000, in
addition to the cost of comp6nsation�amages as provided for in Section 3706
of the Labor Code, interest�arjd a orney'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 be 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 application agrees to, & shall, indemnify
& hold harmless the QiMjf{oft'Indian Apl�"Aits officers, agents and employees.
2. Any permit issued as a resuR 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 isr
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of,this9Ci3y to enter upon the
• above-mentioned property for inp ection purposes..
i Signature (Owner/Agent)-, /r Date
11,
e77 /
ALCM
BUILDING PERMIT
PERMIT§.%1 —141
I
DATE , 7.% W:
VALUATION m,11JU.1 LOT ty
TRACT 26tm
JOB SITE ADDRESS
- 79-190 DJAI � DPiVE
APN
04,311003
,OWNER'—"
CONTRACTOR
e
CL'N'IUR.Y ROMES COMMUNiTIL'S
CRAI "J:°y f"1011.417S Cwj:'1:Zz,.,9NIMES
wc31x SP,'MIT'I D' 9fU.�A 1200
I JJJ
1335 SOUL"H D STREET 9200
SAN Bis.[ NARDINO CA 92.4)8
SAN, MRNARDW, CA 92
(909)3.81-6007 CBLr## 2.1,20
DESIGNER/ENGINEER
WR1-600l
(90
t
i
USE OFPERMIT*A 14GLE FAMILY DWELLING
DU k:EY @ LA, QUiN'1'A NOWfli
PLAN 3XA.
FEE DESCRIPTION
FEES
TRACE CONSTRUCTION 1,618.00 SF
GARAGWCARPOR.'T 417.00 SF
S n I A ED COST OF OCyMSTRU CTION
96,030.60
PERMIT FEE S1.1Mf11,e9.RY
PI, AN C;! l' e`K F1: F 0-439-319 S51S.f h3
-, - MNS!'RUCT10.N FES 101.-000-413-0001 $626.00
Wr`VANICAL M, 101-000-421-000 555.50
ELEZ17R1C;AL FM 101-000-420-000 5128.47
, 0
Pf .►J141._R ING H F.F. 1014.00-419-000 $08,0
5~r OG murm Ian . imsw 100-000-241-000 $9.60
GRADING IFE6 101-000-423-000 $20.00
1NFR.A3'CR,UG 1 f2E t:'1- :225-000-4A3 :342 $4160.69
r
t SUIS -TOTAL C:ONSTRLICTiON AND PLAN CHECK
$3.6M.34
LESS PR.F-.PATD.IJEE.S
$0.00
TOTAL PERMIT FEES DUE NOW
$3,666.34
U i
TOTAL PRWECT PERMIT T FEF -19
V 3 p
3,6".34
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
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation 0(/, /V& 6
Vents
Fireplace P.L.
Grills
Fireplace T.O. 4 49
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
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 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
Final tv
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)
COMMENTS:
Notice:
Document Cannot Be Duplicated
Date 11/28/95
No. 13916
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 604-313-003
Jurisdiction La Quinta
Owner Name Century Homes Communities Permit #
No. _9-190— Street. Diane=Dr:._
City La Quinta zip 92253
Tract # 26188
Type of Development
Comments
Lot # 19
Single Family Residence
Log #
Study Area 232
Square Footage 1618
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 1,618 or $ 2,782.96
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.
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature �g PL1,dkAAA1'A_
Telephone .
r
Payment Received $2;970.44
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