9608-010 (SFD)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
71 +l I i3t+ 13 ,,, r 1.0131 t:7 l"
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 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 3720: iPto•tjbor6ode, for the performance of thelwork-or-which this
„1;�,et .. �.
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 37.0,0„of the Labor,
Code,.l shall forthwith comply with those provisions.
Date: 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, 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
B
BUILDING PERMIT
PERMIT# CONTROL#
"�°�"'” 3 815
DATE1i VALUATION �1 �:P?3i�d LOT
TRACT
JOB SITE 4'%.'d935 VIA JAMN
APN 617_7,9"37
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CEI` i JRY C1•Cf;9WELL COMAr1i1P-lM 11
C,'°;:i'MMY CROUTL L {:(1141MUPd.Ci' Es
1535 s0.'".04
-1515 SO, ".fa" STREET, S E. #200
SAID BERN.ARDIN- CA. 42408
SAN B.1 "KILIANO CA 92409
009M, i-60)07
(009)_A81»6M7 Cl3:t..#t 2)20
USE OF PERMIT
11vt �a1 k;A 'llLY DW I,
COT 37 ilii' MWO
U KRA.t31=lt A1tK)WV 521,0" SF
ESTIAiA IEZ COW OF CONSTRI,it" IOP11
WS."2.20
i ,*HM>IT h EE 5j11MMAKY
TtAN Cf EI'.0 K RX 101-MM19-318
&.$67.6" .
FRE' 101<000-418.000
Sij?8>t)ti
1N4hC14A.N-1CAL Flet 1011-0N-421.0100
$0,00
w.;1AR;, M'fCAL FKP 11x.1 -000? -4),01-00 0
$123::12
PLINFlrNO FEE 101-309-419-000
$148.00
w:fiONOA410I`IONPES�>i .� :� it)l.�£i-?`!1d)0slt
�3I.f11
Com+ #�1}i�rCa fc i 1014100423-000
D .tell
T 3I ttA�;'.tRl) 1(I121 ` �r, a^.2 -000443 M2
$7,47V?8
Alar lit rtTf I.1e; PLAN - RMWID 701-000-235-000
Sdt.31
SUS_ S711LI C'i(. N inND PUN CHECK
$1,'.11.02
n GEIS PRE-PAI17 FTES
D 1,
$01,0)0
Sw4j1111.02 ..
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings KDucts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing/of
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Q
Drywall - Int. Lath /
Final
Final
BLOCKWALL PROVALS
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
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL P OVALS
.Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
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 r _
Indio, CA 92201 '
Document Cannot Be Duplicated 619-775-3500 +
CERTIFICATE OF COMPLIANCE
Date 7/29/96 APN # 617-790-037 `..
No. 14759 Jurisdiction La Quinta
Owner Name Crowell Communities Permit #
No. 47-935• Street Via Jardin Lag #
City La Quinta p Study Area .123
zip 92253 '
Tract # Lot # r Square Footage 1942 '
Type of Development Single Family Residence 'No. of Units 1
Comments
t '
a
At the present time, the Desert Sands Unified School_District does not collect fees. on garages/carports, T.
covered patios/walkways, residential additions under 500 square feet, detached acxssory 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 a-
Code 53080 `
This certifies that school facility fees imposed pursuant to Government-
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 P;
Name on the check �► -�.r
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Ellen atino Payment Received $3,573 $4_
_ `
Check No. 530675 A `
Signature
,,,Collector: Attach, a copy, of county or city plan check application form to district copy for all waovers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting `