9605-030 (SFD)LICENSED CONTRACTOR DECLARATION
U) I herby 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
C\l W Professionals Code, and my License is in full force and effect.
O D C,) License # Lic. Class Exp. Date
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� N �' p ,.•- ter' �'�,...>'`
ZO � Date �, k Signature of Contra
�
U 0) OWNER -BUILDER DECAR
UJ I hereby affirm under penalty of perjury'that I am exempt from the Contractor's
~ U) 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 6wer dt ine pmperty, arh 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)
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
�p I hereby affirm under penalty of perjury one of the following -declarations:
Lo HCC
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �L compensation, as provided for by Section 3700 of the Labor Code, for the
O J 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
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
1�t Z Carrier % hyi`I° ft;, CO. Policy No. 2042666901
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(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 becpme subject to the
workers' compensation laws of California, and'agree that if I should become
subject to the wofkers' compensation,provisions of Section 3700 of the`Labor
3 Code, I shaliA�hw th comply with4ose provisions ---Y F ��
Datecaht_
Warning: Failure to secure WorkersCompensa io� rage is unlawful and
shall subject an employer to criminal,penalti & 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), Date
aY�/LSA
BUILDING PERMIT PERM T# C°NTR°`"
- ��►.��.► 3291
DATE VALUATION�it��t.iti.XQ� LOT' 3 J TRACTa4� 4�I1 i7t
ADDRESSJOB SITE4' i�I `i $t <� JLI`I
APN
OWNER
CONTRACTOR /NDESIGNER /ENGINEERT,yS,lf�.i'4413r0y,.C�{f
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_ �oi7 l�.l4�F... �`�E�k�itirl lr}t1. 0{iiJliiPL'.7
90 "I;" 18,T S - 'E, 4200
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:iAN NIHANAROIN, ('A 1)74 03
SAN 14b'KNARI7INO CA 42409
f(ho' 4-ftf P
!900)A;I,6007 0111110 2120
R? A C',i'ie9i"Y A I_VS 'ii'_�o,
USE OF PERMIT /�
SI? i0l-l' IiAMILY 0Wl1..IJkN,, i
AVIS'.
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NPINNAKI3, (AWL, frl� I>A.KP LA 1,19 I -A
FSTINIATED C ST OF CON.' ►TRUCTION
1410.895,21)
PERMIT WE SUMMARY
Pl , A?4 (:'FTS .M. a, FV $'r8 44
CONZMRI 1014 FQ,' 101.000 -418 -WO 5923-W
iFti;CHANit,:A4.I'l: s S79 U
H1✓�� 17RICAL >~ . 10"4-000-4420-M $169x74
Pi,t f131 r r x i 101.{)c -4194x(1 $185,75
`•iil`3etiC 120'I'YC.j's� F:iik • �I?S.fl.� 1Q1�i�f10�2�l1^U�F4D $I8.(1)
CSitAU1NIC3 I+fi�, 101 -000 -4,23 -OW S20. N
rNFIZ/ STRtK;'T't,R. M 22, x-000-443-342 84,Ir30.14
:AT 704-000-M-I}M ?,N
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511_' . • �'. filv��a"l It4.ft '1`1(�N :AA313 .I,1 �J CHE,C
S6,3, ►p
�
. LES PRE -PAID FEES
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3�t)1tE1"
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD "
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
/ (o
Final
FinalPOOLS-SPAS
BLOCKWALL APPROVALS
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
9(,
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 Test7111719
1,177
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
Not, e: :.'
Indio, CA 92201
Document Cannot* Be Duplicated 619-775-3500 • .
CERTIFICATE OF COMPLIANCE • ti,i
Date 5/3/96 APN # 643-130-043
- •
No. 14437 Jurisdiction La.Quinta
Owner Name Century Crowell Communities. Permit # '
No. 47880 Street Via Jardin I,,g #
City La Quinta Zip 92253 Study Area 123
Tract # - , . Lot # Square Footage 3104
Type of Development Single Family Residence No. of,Units
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•ac:�essory 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 '
4
This certifies:that school facility fees imposed pursuant to Government CodE 53080
in the amount of 1.72 X 3,104 or $ 5,338.88
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 Crowell Communities Spinnaker Cove LP ,M3 Telephone, 909'381-6007
Name on the check '
By Dolores A. Ballesteros tp It
Superintendent
4_
s 1., _
Fee collected /exempted by Pauline Pearson Payment Received $5,338.88
Check No.. 102314 b .
Signature n
0 .P11i1l�PyY�
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