9608-012 (SFD)LICENSED CONTRACTOR DECLARATION
Lhereby.affirm under penalty of perjury that I am licensed under provisions of
!16apter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals. Code, and my License is in full force and effect. .
License "Wigg g �LIc. Class Exp. D lti113119•f
Date'" r r� Signature of Contractor'
OWNER -BUILDER DECLARATION. �r
I hereby affirm under penalty of perjury that I am exempt°from the Contractor's
License Law for the following reason:
( ) 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, a5 OWner OT ine prapOrty, ani 650UsiVe1y 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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700.of,„the Labor -Code, for the performance of the,work.,foi.which this
permit is Issued. My wor%kers compensation insurance carrier & policy no. are:
Carrier Policy No.
(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
subject to the workers' compensation provisions of Section 3700 of the Labor.
Code, I shall forthwith comply with those provisions.
Date: AoO�... e Applicant
Warning'f ailure to secure Works Compensation cover getris-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 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)--r”--" Date f'
BUILDING PERMIT
PERMIT' 609.01
CONTROL//
DATE *` VALUATION .��{�YBSl:7.>ii LOT
TRACT
381-4
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
c��1" r1t�� (.: r��.r 1✓1, 4�;���trrr�l1.1,
UINrIIANCR,0W ALL CONI&I;.MfIES
1535 so. -Da 5f -REST, y."a'%�. 0.2cH)
1535 SG. "D" S"7AUP,i S" 'K
#200
SAN URNAMAN, CA 92409
SAN MNx RDINO CA 92408
(409)381.6007(910V)391-64117
rv:UN 2120
USE OF PERMIT
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190,395.24)
MAN (N -TEC: K >! E:R 101.000-439-318
.3768.44
CIONSTRUMC-N MW* 101-000-41 '1923A.00
iv`ki-CHANICAL t M 101.000.4214100
►79.00
C-I.E.CTRI.CA!, FRE 101-(M-420-0(9)
SIA9.74
PLUM.13INO RF 1111.000-419410
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34,070.14
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INSPECTION RECORD
f OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 101J411k, 41
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap 9
F.A.U.
Framing 14
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 / / (o
Final
Final
BLOCKWALL APPROVAILS
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 APPR VALS
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:
A
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201 "
Document Cannot Be Duplicated' 619-775-3500 -
t,
CERTIFICATE OF COMPLIANCE
Date 7/29/96 APN # 617-790-045
c
No. 14761 Jurisdiction La Quinta ._
Owner Name Century Crowell Communities Permit #
No. 47-820. Street Via Jardin Ug #
City La Quinta zip 92253 Study Area 123. ,
Tract # Lot # 'Square Footage 3104
Type of Development Single Family Residence No. of Units 1
Comments
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 1.84 x 3,104 or $5,711.36 w
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 M , Telephone-,,
Name on the check
S mrW
By Dr. Carol McGrew �r=,
Administrator-inCharge .'`s `" ^Yf .
a , "
i^f�_� �fp
Fee collected /exempted by Ellen Patino Payment Received ' $'5; 711.36'
F Check No. 530675
Signature
101 Collector: Attach a copy of county or city plan check application form to district copy for all waWers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting