9512-131 (AR)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
oW Section 7000) of Division 3 of the Business and Professionals Code, and my
Q LOLicense is in full force and effect.
i- W License # Lic. Class Exp. Date
r- CC
Date Signatureof Contractor
o� Zn
cT0 0 OWNER -BUILDER DECLARATION
J lUCD I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
(n ( ) 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. 7044, Business & Professionals Code).
( ) I am exempt under Section B&P.C. for this reason
�
Date Signature of Owner
N
O rn WORKER'S COMPENSATION DECLARATION
dQ I hereby affirm under penalty of perjury one of the following declarations:
Z () I have and will maintain a certificate of consent to self -insure for workers'
LO <O 11 compensation, as provided for by Section 3700 of the Labor Code, for the
X W U- 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 U Section 3700 of the Labor Code, for the performance of the work for which this
O () permit is issued. My workers' compensation insurance carrier & policy no. are:
EL LO Carrier Policy No.
? Z (This section need not be completed if the permit valuation is for $100.00 or less).
00 =) () 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 of Section 3700 of the Labor
ti • Code, I shall forthwith comply with those provisions.
Date: Applicant
3 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, 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 result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 to enter upon the
• above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date -
ALC #
ate
ALCM
BUILDING PERMIT
PERMIT S12-131
DATE 12J27/95
VALUATION 510,263.40LOT TRACT
JOB SITE ADDRESS
52-190 Eimiha�s er Dr.
APN
I 773-232-009
OWNER
CONTRACTOR
Ownef/Ruilder
DANITFL & FEADEL1NF CRdUTORD
Saute as above
52190 .EISFNHOWEIZ DR
LA QLIINIA CA 92253
CBL#
DESIGNER/ENGINEER
`
USE OF PERMITxuon 1UN
IfOof KttcJtett Additkm
FEE DESCRIPTION
FEES
VALUATION 10.263.001.8
ESTIMATED COST OF C{3NSTRUIi"FIONN
10,263.00
PE14MIT !+11E NIJiMMAHV
t�L AP1 C14F(X ME 101.400-4.39-318 SS l.IO
CONSMUTC7ION FSE 101-000-418-000 W26.00
STONO MOTION FFF - RE;i1U 100.000-241.-000 $1.03
ELIENARICAT. FEE 101-000-420-00 $18.78
SUE -TOTAL. CONSI'RUC' ION AND PLAN CHECK
$227.7.1
LESS PRF, -PAID PEES
$0.00
�_4 O TO'I AL ERtt IT fi'F&S DUE, NOW
$227.71
1 P1996
RECEIPT
BY
DATE FINALED
INSPECTOR
INSPECTION RECORY
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS.
Set Backs / /%/L
Underground Ducts
Forms & Footings L
Ducts
Slab Grade
Return Air
Steel L
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor..
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath -
Drywall - Int. Lath /
Final
Final
BLOCKWALL A P . OVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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:
F
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Du
Indio, C'A 9.2,201.
Duplicated p 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 1/4/96
No. 14013
APN # 773-213-009
Jurisdiction La Ouinta
Owner Name Daniel P. Crawford, Jr.
No.. 521-90 Street f Eisenitower_ Dr!
City La Quinta Zip 92253
Permit #
Log #
Study Area 112
Tract # Lot # Square Footage 189
Type of Development Residential Addition No. of Units 1
Comments
Citchen Addition
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:.
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 0.00 X -189 or $0.00
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 n/a Telephone -
' Y ,
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by. Pauline Pearson Exempt
Check No. n/a
Signature a,&! .o
$0.00
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copv - ApWicant/Receim Copy - Accounting
n