9603-024 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am14licensed 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
7I I1�l# k� 1.41rt4rlr i1��;!
Date TrI 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 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier UNJC Altar 114SURANC Policy No. :aA:2 _04- v` -W
(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,p"rovislo s of Section "3700 -of -the Labor
Code,.l,sh �I forthwith comply with`those`pro !dons:-
Date: / 1'/ (ppllcant _ ✓ -�� `,=�
rte`..,.::;-''" • r .
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 Jaws relating to the building
construction, and hereby authorize- representatives of this City to enter upon
the above-mentioned property' for inspection purposes.
Signature (OwnedAge' nt) Dated
PERMIT# CONTROL#
BUILDING PERMIT _W114-024 2967
DATE �Jl)f, VALUATION �iy � �,f±d� LOT —Rfi TRACE{S;P 3"f{Atit, jy;,
I
JOB SITE
ADDRESS -4,
643-13"42
OWNER
CONTRACTOR / DESIGNER / ENGINEER
(T.N11JftYCRcAITU COraNzONt~r ES
153:1 iia. '06 S'i7{.Ei I, �n E. #200 -
15-35 ,SO, `0- ;; IT LEV'I', 81T. #200
SA1\ TJ ?RKA.kD1Nl CA 92400
SAN 813 R.N AR DING CA 92,1413
(000 8111 007
(900)38i407 CSL9 7110
y`ity`et%,V; +iditq.j �`j L PiiiEalXr��{ {.
USE OF PERMIT
tar c � ,t? H�1Rlfl. IlWh .%,{Ivc
C.430 €;ASW CHAPM.AN AVE.
SPINNAKER C'f:)VF tai': t .r M' LA QITINTA.
{
PLAN 4(X(7R
4rA3tAt:+f3i(.�Ai41'(:)12'i' �:i().s�Ct $ib
TR AC`f MMMUCTf ON 1104.00 SF
'ESTMii ED COST (Al1101-s kU(iON
1160,85�16
.
PERMIT EE SUMMARY
.
SRT 4N Pf.IYt A<1 t9J,ACVS M RVAt', 7014)t10-251-000 bio 24
CONSi`It1.i'C7110 +1".l rffi" l tf l rf `J -11.E -C44() 392 .0®
f1'f,C.` kICoAL) (f3 it}i�n a2atxa� �� �
C3£I rii l3+fc; .FSI? I f) I d)Cf042.34i0O Zit Crt)
Ihll.fl.ASB1ti€f"tlff Fi 1 '?9i-f!().Q-# ' $4,f)'70 34
AIEC14rVNMC;AI. W10 101. fJOO�9 1-U(IIe $' t�lf
I'I. AN C`HIXK FLE 101-000-439,-318 $748.44
PIsLfA lt�CCI.F> Fs 101-OW-41�)-000 318515
51,11 ` w; )IOcs'i":MVUTI - RfIISID i Ol -000-24.1-ow $1.8.9
c::ONST' U'CTION A ND PLAN CHI -;CTC
1X85 PRP-PAIDIT ES
S6,435,90
fit) Oi)
TO t, rERINUT FIKES DUE NOW
MARrp
1 g
S6,435M)
1996 '
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath j
Final
Final
POOLS - SPAS
BLOCKWALL APPROVAi,$
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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 44
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
Desert Sands Unified School District
Notice:82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 3/18/96 APN # 643-130-042
No. 14259 Jurisdiction La Quinta
Owner Name Century Homes Communities Permit # ,
No. 47910 . „ Street Via Jardin Log #
City La Quinta zip 92253 Study Area 123
Tract # Lot # Square Footage 3104
Type of Development Single Family Residence .-No. of Units 1
Comments
I.. *
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 1.72 x 3,104 or $5,338.88
the property listed above and that building permits and/or Certificates of OccupEncy for
this square footage in this proposed project may now be issued.,
Fees Paid By Century. Homes/Spinnaker Cove LP - Xe,Jelephonez,
909=3'8.1' 007
Name on the check
.. r
,.i, i•o fry e...
By . Dolores A. Ballesteros - F
, x
Superintendent
fir -
Fee collected /exempted by Pauline Pearson Payment Received \4 $5 338.88
Check No. 101043
t Signature ro A€'nitQ V -o Hti1 Al �M
x^
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