9608-008 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chanter 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 14i9 B 10131f 7
• r.:
Date 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
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pen6lty 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 37004of-tft� abor&ode, for the performance of thew,qjk,;Jgrjwhich this
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 provisions of Section,3700 of the Labor
Code,.I shall forthwith comply with those provisions.
Date: -� �Y Applicant—
Warning:
pplicant 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, indemnity
& 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 fo.r: inspection purposes. r
Signature (Owner/Agent)' Date
BUILDING PERMIT PERMIT# CONTROL#
,31,E 3 317
DATE 412196 VALUATION � � ��� • � •+ LOT TRACT
JOB SITE 4 I-87;.`9 Vi A JttlW.If NAPN
60-7964 j5
ADDRESS
OWNER
CONTRACTOR /DESIGNER
..,C IvJkT1}. CON tp UI {1 E.',,
(111t 111R"..,
//ENGINEER
jt.6tL'4.�1\. �7• S
tt�pCq•y�
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13315 Jo. 10011 �?UIS�.P.S.[:��1. Solt. #200
SA'N K6, R NAK1XN- (IA. 92408
SAN B13121i1.A.R DINO CA 92+105
t 00)3ft i -6007
f t►I3+?,l l uG0£i7 0131.0 2120
USE OF PERMIT
31NC.i1,F '(�E�14111.,�r' ����1,iat::i►�ft:S
•
0A1tAt13s/L:ARI)CIRT 6"W.00 SF
ESTIMATED =VF OF CONST
1,61,184.30
NX421iI IT ii'0, 3l1Aa1«ARY
PL AN CHF:CV. F; RE3s 1.111 �0(N1-�# iy :1 i K 571.1.12
�'S�NS7f U�;ITcO:�iF'L:I 10!-Q40-41809 38Sffi,5;+
Ni'1:c:IIAid(CAL .kkW 101 -000421 -OW $79.00
PLEC`M(CAL F'RF? 101_0("2(1-0013 $157.04
PLUIN181-wo FW_ 1.0t-0004,19-000 $'f f 1.2.i
STS)1�10 AiG�Tfc'S1,F F1�_ '�.Itt?St�.� 1t}.�;,i-2f�1�0 $36.:t'
l,s1Zf P11 V .C'1'SL i{ii 1")t} 1 8-iM3G $20,00
INFP,A3T3t1Jf."1 W-., rJ%" 22.54)00.4 .X42 $x,626.65
ART IN PUALIC PLACFS - ftrt ; 7014)00-155-4)00
SLffl-M- AJ, CONSTRUCrION AND PLAN CHECK
$5,781,24
LESS PRE -:PAID FEES
W00
_ o F : U, PC, RMIT FEMS DUE NONY
V%791,24..
:D
AUG 0 9 1996
RECEIPT
DATE "^,- - �..�
'By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 0
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation d
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath /
Drywall - Int. Lath
Final
FinalPOOLS
BLOCKWALL OVALS
- 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 44za4Pool
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
Notice: 82-879 Highway 111
Indio, CA 92201 ,
Document Cannot Be Duplicated 619-775-3500..
CERTIFICATE OF COMPLIANCE t
Date 7/29/96 API #, 617-790-035
No. 14757 Jurisdiction La Quinta.
Owner Name Century Crowell Communities . % ,Permit #
No. 47-875 Street Via Jardin ' i Log # ;
City La Quinta Zip 92253 Study Area 123 t,. .
Tract #2741
Lot # Square Footage
,
TypCof Development- Single Family Residence ' No. of Units
Comments
At the present time, the Desert Sands Unified School District does not collect feeE 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 2,741 or $5,043.44 <t
i the property listed above and that building permits and/or Certificates of, Occupdricy for ,
this square footage in this proposed project may now be issued. -
Fees Paid By Foothill Independent Bank # T ele'phor�e t
y: a
Name on the checkf
By Dr. Carol McGrew
Administrator in Charge 'L*�� y t'
Fee collected /exempted by Ellen Patino Payment Received EF $�r0,
r43}.44
Check No.
530675 i
Signature #
Collector: Attach a copy of county or city plan check application form to district copy,for all wavers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting