9608-013 (SFD)LICENSED CONTRACTOR DECLARATION
U) 1 �)ereby affirm under penalty of perjury'that I am licensed under provisions of
~°i" 'Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c� w Professionals Code, and my License is in full force and effect.
p License -1141188 Hc. Class Ile Exp. Dat0e
T
LIJ
Z r- Date Signature of Contractor"' M _
O
U rn OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
~ (D License Law for the 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).
( ) 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
U
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
C) IM I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
OU Q Section 3?,094o(•it�igiwLabortCode, for the performance of thhelwoxkyfgjjwhich this
LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
�O
J(This section need not be completed if the permit valuation is for $100.00 or less).
() 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
3 subject to the workers' compensation provisions of Section 370Q of. the Labor
Code, I shall forthwith comply with those provisions:
Date: sT r'e Applicant
Warning: Failure to secure Workers' Compensation coverage:is•unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, Jn
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 applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, 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 '
BUILDING PERMIT
PERM 9 CONTROL
�'���'� 3819
DATE 2�1 VALUATION' Jf.�.�e�i(ix•LOT
TRACT
JOB SITE 47-94S VIA JA 4'1.DUN
APN 617490-034
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY CROW ELL C{aMh1r11` MIDI :
C.ENIII RY CttOWE,,;L COit4R!Jt, !Irt 1ES
1535 so. -D. Sucam, snz. #200
SAN'13UMNAR.011�, CA 92408
SAN 811IRNAt2UINO CA 92408
(00)381-CO07
(009)36!-6002 212
USE OF PERMIT
S1Nvi..H` .ii'.Aty LY t W'PL ,fNG
(tllil�Ct;%+vllflfd 3lt'! $31,41) SF
IYtAL !' C(5A1�31*lil)C: Cik31�1 102 .0 Sf
US'1i 1SUXfE D C09t OF CONSTRUCTION
J IS166i.20
pf.? 10TECK MR. 101 -OW -439-318
CONSTJtUi"1"i0N FIX 101-000-418-000
$678.09
Nk Cl:•1AWC,ALFES 1014100-4 1.00(;
$0.00
Ff,ECTR.I At. F -ER 101-000420-000
5.123.32
PLfSJ41RTNO FEE 101.000-419-000 '
$1448.00
S1*0NKD:X1C r101q'tF�E RES'ID 101-000-241.-000
$11.01
1GR_4D1NG l�:E . 101 -0310 -423 -Celt)
0420.ch)
1NFI2Afi`.fTz[I+,"1'CTf1t FIr#"s. 225 -NO -443-34)
$2.4177,78
ART IN PLTOLIC PLACES - KE. -SM, 701.000 -2.54 -NO
s2S-31
SUMI-"1.O'3'AL CC?NS"'rTt1Je„DON ANIS PLAN CHECK.
$4,1.11.02,
�- -- - LESS 1>:Ct."fc-:Er1ID FFGS
-A
$0.00
D QTA1l, PERMIT 1 EES' OVENOW
$4111,02.,
AUG 0.9 1996
Qy
RECEIPT
DATE
BY i
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 14
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap Q
F.A.U.
FramingCompressor
Insulation d
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Q
Drywall - Int. Lath Q
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 6
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 / G
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201 ,
Document Cannot BeDuplicated 619-775-3500 '
-
'CERTIFICATE OF COMPLIANCE
Date 7/29/96 APIC# 617-790-034
No. 14756 Jurisdiction La Quinta
Owner Name CenturyCrowell Communities Permit # .'
No, 47-845 Street Via Jardin Lo; #
City La Quinta zip 92253 Study Area, 123'
Tract # ` Lot # Square Footage 1942. r` `
r_ Type of Development Single Family Residence a leo. of Units 1
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, r
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 1.84 X 1,942 or $ 3,573.28
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 Foothill Independent Bank Telephone
Name on the checkBy
Dr. Carol McGrew
Administrator iq Charge ' t
Fee pry collected'/exem ted b ' Ellen Patino Pay' ment Received .'.. `'• - ,
p Y $3,,73:28_
530675
Check No. .
Signature L
(, . 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,
. 1, :