9608-011 (SFD)A LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date „
i l 4198 IA ,r 0f'A i
Date f f. a f - Signature of Contractor
OWNER -BUILDER DECLARATION
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
i,udu).
( ) 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 3700Jol,&%�gbZr(Code, for the performance of t�e1wgrk-tf? which this
)07
permit is• Issued. My workers' 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.Pr6visions of Sectiom3700 of the Labor
Code, I shall forthwith comply with those provisions ,"+ ,-
Date.. � S j r Applicant ` •y` *� �'"'
Warning Failure to secure Workers' Compensation coverage Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter, upon
the above-mentioned property for inspection purposes. P
Signature (Owner/Agent) Date
BUILDING PERMIT
PERMIT #
°°NTR°`#
3 813
DATE VALUATION `liliil•i+S$-ii1 LOT
TRACT
JOB SITE 4.7-h.% VIA Jikit DIN
APN -6.17-790-"4
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
411?i`11'i 1 it )" C, l:t) 'IV I11.1111,(AN If IUt,xl`I I
CHN"1'1A:Y: a'R.i?iL'E?<,,L I(X;3MMUNITIES
1 535 O. '''W I+ 1'Ii.1'.r,,T, �" `.I"i. ii'200
1335 $0, `D" 6;MEET, S*IE. #200
SAN fii:RNA.RDIN' CA 42408
SAN BE RNA1UNNO
CA 92408
t'�W)181,4)07
CALF! MO
USE OF PERMIT
S1Nuf,1:. FANi(1A" 1:ii+liELLIN
1�r eta at}A;if�13 �
Z.T.AILA1.hiC;ilE2.E't.,lft'1' .`f3�1t.00 «y��i
1'.EHM,I'i VEX 4UI4`ilMlARV
PLANT CI1KX.F'ER 10140-439-31.8
$711..72
CONS'MVIC'TION KIF,' 101-000-418-000
$856.51)
TVIE HASdI AL FEE 101-000-421-00U
$79.00
I,4X-',C17 1CAL, 0713, 101 -000 -420 -WO
3157-04
PIXIMBING FFH1, 101 -OW -419-000
$161.13
ST(SNC iLiC` i tL?N Fa: -1u.- SID 1411-00�t0-2441,,.000
$ M 12
' GRAlr�.fl�C4 ME , 01 -OW -423-000
520.00
11NFRASfRUC URE FEE 225 -WO -441-342
A,Wr axe,PtT01.1C PLAM - 9FSf£, 701 -000 -255 -NO
S152.915
SU840TAi. CONSTRUC.'1'ION AND PLAN ClItt:K
S5,781.24
LESS PRE -PAID PEFS"
$0.00
OTA I'E1`XA7IT WKS I)(JE NOW
$5,7:111.24 .
1
U
AUG 0 9 1996
.
RECEIPT -"""-°-'f.._
DATE
BY
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
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
p
Compressor
Insulation MAN~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 6
BLOCKWALL APPROVALS
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 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:
Desert Sands Unified School District
' 82-879 Highway 111 t
Notice: r,' � � � .
Indio, CA 92201
Document Cannot Be;Duplicated, 619-775-3500 r
„ CERTIFICATE OF COMPLIANCE
Date 7/29/96 ' APN # 617-790-044
No. 14760 Jurisdiction La Qu_nta "
Owner Name
Century Crowell Communities Permit #
_
No. 47-850 Street Via Jardin Log # "
City,La Quinta Zip 92253 Study Area 123
Tract # ! Lot # Square Footage 2741
Type of Development Single Family Residence 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, detachec 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:
A°
EXEMPTION NOT APPLICABLE y
This certifies that school facility, fees imposed pursuant to Government Code 53080
in the amount of 1.84 x 2,741 or $ 5,043.44
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 check
By Dr. Carol McGrew , i {?
Administrator in Chargeg 4$'
Fee collected exem ed by Ellen Patino Payment Received $5a;)'043'
44 ,
L
Check No. 530675 .
Signature v
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