9511-136 (SFD)cn LICENSED CONTRACTOR DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
Q � License is in full force and effect. 3144.73 R 1.131196
riW n License # . �^ Lic. Class . 0 Exp. Date ✓'
t^. r- Date ,/%�.:SignatureofContractor
c'o 0 o> T OWNER -BUILDER CLA' KAON
J w GD 1 hereby affirm that I am exempt from tie Contractor's License Law for the
a 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code).
( ) I am exempt under Section B&P.C, for this reason
�
, Date _ Signature of Owner
N1
0 WORKER'S COMPENSATION DECLARATION
U _Q I hereby affirm under penalty of perjury one of the following declarations:
o g�Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
LOcc �O compensation, as provided for by Section 3700 of the Labor Code, for the
X W LL. performance of the work for which this permit is issued.
O J J ( ) I have and will maintain workers' compensation insurance, as required by
03 Q 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:
d rn Carrier Policy No.
? (This secti6&ii 4'ae h, dt,libTBompleted if the permit valuatidNi6farl$1.00.00 or less).
Z)() 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• R ection 3700 of -the -Labor
Code, 1'shall forthwith comply with thos�erpr visions.
ate: l ";Applicant
Dy�
_C
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, intarest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a3result. of this application agrees to, & shall, indemnify.
& hold harmless the ChAfi` LeipjW,ellr.�lts officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I
I certify that I have read thisaPP lication and state.that the above information is
correct. I agree to comply with all City, and-$iate laws relating to the building I
construction, and hereby authori;Wrepreseeritatives of this City to enter upon the
pecti
above-mentioned.property forinson'pur oses.
Signature (Owner/Agent,,!i' Date at
x�
A"'
.._ BUILDING PERMIT
PERM'T
DATE
VALUATION " ^' • LOT I `F
TRACT
JOB SITE ADDRESS
APN . 6i)4-312_006
i
OWNER
CONTRACTOR
C%;j�1°!"In(.CTt1�'�y�t��I��p,1j�l�&1:'ErtSS} Cafi?.li-Mf1fNYffES
1�^^�� A ��., {yy��1 �C� 1/'�1 AA•� (T7 ��T�••�.�++ii�N�.
F..1 it'n ply 1"L� NIE4S Colfl%f 1, Y.(f frls
1:-535 s� urli D S�1�7t.7_' 1,1 ##"0 !
1335 SOUTH,1) &IrRE6 C' 4200
SAN UERNARD.[00 CA. 92408
SAN B1w12KA.i23)IN, Cq. 92408
(9AM.'s-007 CBL# 2121)
� 9J3S!"6�7
DESIGNERIENGINEER
USEOFPERWtA1NQLk 1 Vl Li xJ ''L ,1iN4J
.DFA, .12EY @ LA QUINTA..NOXI-E
PUUq 2XAR.
FEE DESCRIPTION
FEES
'11, AC'T' C ON81'RUC:TION 1,478,00 yF'
GARACCICARPOWl' 413.110 S
FA'1I11 ATEO COST OF CONSTRUCTION
/ 88,350.20
_PER'iV IT 11 EE SUlkil4IAlRY
f: LAN C.k•MCK FEE' 101-000-439":418 $499.47
CO NS'l'R.UCT10N FEE 101-000-418-000 S5901W
h&X IIANICAL }SEI; 1.01 -MO -421-00b 549.00
ELECTRICAL FIVE 101-000-420-000 $123.4-1
Pi.>:Jl4BING'M-1. . 101-000-4194" $IX,00
S'. ONG A40110N ME E - RESID IMOOO-241-000 $8.84
M10 (NO F € S '101 -000 -423 -ON 520.04)
LNFRAS RUC -PURL FEE 225-000-443-342 St•987.88
SU.E 40TAL CONS17RUCTION AND PLAN CHECK
$3;4.16.6£3
LESS PRE -PAID FEES
$0.00
�n1
r-� TOTAL PERMIT FEES DUE ()W
$3,444.63
I
IOV 31 0 1995 TOTAL PRO.IEd:� PERMIT FEES
3,414.68
RECEIPT ^--
°DATE
BY
DATE FlNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
/"00010,
Ducts
Slab Grade
_
Return Air
Steel
A
Combustion Air
Roof DeckMV.
Exhaust Fans
O.K. to WrapF.A.U:
Framing711
: Y(k
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
2 L
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
YZ
Final
Final h*'
BLOCKWALL. APKALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
i
Final
Utility Notice (Gas)
ELECTRICAL APPROVAL
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 Z tZY
Utility Notice (Perm)
COMMENTS: w
Notice:
Document Cannot Be Duplicated
Date 11/28/95
No. 13911
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Nameentury Homes Commities
APN # 604-312-006
Jurisdiction La Quinta
79195 __ _- Street - Diane -Dr!
City La Quinta zip 92253
Tract # 26188 Lot # 14
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area 232
Square Footage 1478
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 1,478 or $ 2,542.16
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 AssociatesL.P. Telephone
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $2,542.16
Check No. 22479
Signature
LLk ,�R &AA ��
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