9511-142 (SFD)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I 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 iQ full force and effect. 314.473 B ,�.y-'$i'311�ti
� WW License # / Lia Class " , ,."Exp_.Aate,'
r- Z Date r' _ Sig nature ofContractor
r .•''` .�!''r -
E.
cTo OWNER -BUILDER L RAI ION
J W 1 hereby affirm that I am exempt from tFte#Contractor's 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. 70,44, Business & Professionals Code).
() I, 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
M Date Signature of Owner
LO
N
rn WORKER'S COMPENSATION DECLARATION
CL Q 1 hereby affirm under penalty of perjury one of the following declarations:
g Z () I have and will maintain a certificate of consent to self -insure for workers'
LOWO 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.
p J J ( ) I have and will maintain workers' compensation insurance, as required by
C0 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:
a rn Carrier Policy No.
IT ? (This sectio need nott b plated if the permit valuationis;Jor $1.00.00 or less).
N 1 �l)i�ltl , t , .V491A
r` Q () I certi ' that in a performance of the - work for whic Phis 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 odld become
subject to Yie workers' compensation provisions of-Qecti n,3700 of the Labor
Code, I 'sh II forthwith comply with Utose provisions.
Date:e 1 Applicant s� -
1
Warning: Failure to secure Workers' Co�s;4" n 0" verage 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
� P 9
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 assult of this application agrees to, & shall, indemnify
& hold harmless the � In
redlanylye%t 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 informatiori lis
correct. I agree to comply with all City, and State laws,relating to the building
construction, and hereby authorize,---- rpresentatives. of tt�iis City to enter upon', the
• above-mentioned prope�orinspection-purposes. �a
Signature (Owner/Agger' 4 Date/
A""
BUILDING PERMIT
PERMITi.�B�-t�z
Y
DATE 411YO
VALUATION � -AJ, C LOT ,e
TRACT Z0166
JOOB SITE ADDRESS 79.200,DIANE DRIVE,
APN 6"313-4*4
OWNER
CONTRACTOR
CCld'1�'T'I(av, imms Comm-_i>rtt' ns,
{ 7�j�{y j �l �7 ; p j 7�.j��^{�
tns 41%9 ,11v AAV. MFS C,1)NI/b�+LIJ if.i �,i.,!.J
1515'S(.XJTfTH v 9 M ft"' le
1.535 SOU1'.H D 317REH I 4200
SAN SSE:RNARDINO CA 92408
`AN K:RN.ARDIN, CA 92408
1909)384-6007 CB1.# 2170
1 )3 1^6007
DESIGNEWENGINEER
USE OF PERMIOTNGLE FA11111L i DWELLING
DU REY tO LA: QIJFf%1 A.NOXfH
PLAN' XXAR
- FEE DESCRIPTION
FEES
TRACT;.CONS'P1ilir;,'1• 0IN 1,478.00 SF
GARX01HICARP()XT 4.1100 S1:
M A.TEO COST OF CONSTRUCTION
138„350.24
PERM(T I+' IE SUMMARY
P1LAN C1• ECK FF9 101.OfM)-4.04<3.iR $439.47
CGNSTMUCI ION, F12 101-000-413-000 $5.90.00
MEM"CAL rEJE 10.1-000-42.1.000 $49.00
OXCTRIC;AL FEE 101 -OW -420-000 512149
!''1.'U11 RING FOR, 101-000-11.9-000
VONG MOTION F'it W RESM I00.000=2 91-000 $3.34
GR AD I NO F) XM 101-000-423-000 • $20.00
e .
INF"RA,S'`I RLA-7f M FEE 22_5�443-342 $1,9b'7.58
13-iQT1iL Cl7A)S'TRIJC'i'ION AND PLAN CHECK
$3,416.68
i� a LESS PRE. -PAID P'.RGrS
50.00
• #+'E+' �' ' Ih
; TOT -A
S3,414,”
:�V � 0 1995 I�..
`-' iDTAT, PSR( WCT i'ERA11 FEES'
M
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
a
INSPECTION. RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings 7 Ducts
Slab Grade 4010V Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K. to Wrap F.A.U.
Framing Compressor
Insulation f rVents
Fireplace P.L. Grills
Fireplace T.O. Fans &Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final R POOLS -SPAS
BLOCKWALLP OVAL S steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Gas PipingGas
I
T
PLUMBING APPROVALS Elecc F
tinal
Waste Lines Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.IC for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection AEncapsulation
Gas Piping
I
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
r i
Final
Utility Notice (Perm)
.�
I
Notice:
Document Cannot Be Duplicated
Date 11/29/95
No. 13921
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Owner Name Century Homes Communities
APN # 604-313-004
Jurisdiction La Quinta
79200: _ StreeDianeDr ,,
No. 9
City La Quinta - -- zip 92253
Tract # 26188 Lot # 20
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 Associates L.P. Telephone-
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature ��I QM- A -L
Payment Received $2,542.16
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