9603-023 (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.
LicenseLic. Class Exp. Date ,
A41K4 {c IV��I �fI
Date -11 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am. a *empt 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, ant 6Y610IV@ly 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 4.�NWARE lda` URANC Policy No. ''A �-01���-�'�
(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 th�fl should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I_shall forthwith comply with those provisions
Date: 2' ff F I'LL Applicant
Warningi Failure to secure Workers Com rxsation coverage is unlawful and
shall subject an employer to criminal perYa tl ies 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 la�xrelating to the building
construction, and hereby authorize rep'resentattive`s of this City to enter upon
the above-mentioned property forinspection-inspection
� y„
Signature (Owner/Agent): '`�� �Date� r , 65'
,6BUILDING�,P�RMIT ,LPE/ 4 ►�.�xy j<;,S2 say t 6
,,,
DATE VALUATION LOT TRACT
i
JOB SITE = 2y-if1 dl �c4>�C1l�Ill�t
APN
/X
ADDRESS f
OWNER
CONTRACTOR / DESIGNERENGINEER
77 t t S' �y {�y Y ; t y�d1 rC
C11P 1I R 6 �ti�,OU E:�i. l ���� INIk4I. Ni:TiE
(/
�:�.c:�t�i�(i.���� l}iiJ�}t i�,f.i� tr Sd1Y�l��l kd 6v l.t•ii'. i
1135 SO. "U" 9M 20U .
15:37 W. "Do S`[li.EVr �;"TE. 4200
NAN 43E.RNAK[AN, CA 42463
SAN BE Nt\t2.DINC) CA 92400
('3t}4)Y�` i-iifti)?
(4�±�)��l-FQ(1'T �•"��f,?� ?i °Qt
USE OF PERMIT
SiNOLE PAWLY DWRNAA1401
!it:'INNAKVR fX)VR Ca LAKE LA QQINTA
ill' AN 1BOR
{}ARA iFJCAt2!-)0W.I' - 41Y,00 aF
'I•kAtvT l''ONS'I'E2"WNCI N 1,94' 00 SF
r.S 11U1 x..11 OUST ()F CUNS RI1UTit re
iij.663.00
:PFfiMIT ME itUMMARN'
A!2' 114 Pf PLIC. Pt.AC17,5; S3416
i.[*(:f t'tt�"•AL Hili lt3t-(i(itj. 2U-(i0ii t7a.kt5
�f)ZJ',f�f�;4}F'f�.ls' It�t-E�fltf--1'mz�t100 . �`L'fi.fJt!
I N1WR ASTRI RI Wrrf tR V 1, Tf: h 4 000-<1,11.347
N11EXIIr' NP7,11..I EE I 000 Q1-000 "c�tta�fi
POOL f t lfL- I 04*" tti)j dt llt*�F+'>-1(t5 is'�:Qty
?�I.li�ffSffJff t°t•(� '�l4tff tlf!
�°� {lfitl �iyt�O��K�'!l�I,IJU{q)
SURVIUt.aL (:: jI4t Tk�f.I �iI��N.QLPfi} PLAN (110-111L
$A,219, 79
LESS PRE',PAID MIS
Z/-
$(06
- -R 18 1996 i
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 i
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath i
Drywall - Int. Lath $�
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 2
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral I I At
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
Notice:.. 82-879 Highway 111;
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 3/18/96 _ APN # 643-130-041
No. 14258 Jurisdiction La Quinta
Owner Name Century "Homes Communities Permit #
No.. 47940 Street Via Jardin L,g #
i City La Quinta . _ zip 92253 ti Study Area 123
Tract # Lot # Square Footage 1942
Type of Development Single Family Residence
No. of Units 1
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 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:
. S
EXEMPTION NOT APPLICABLE
• This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1:72 - x 1,942 or $3,340.24
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 B h '�P •;;
y Century Homes/Spinnaker Cove LP `? ,Telenhone-'909-3181-6007
Name on the check
By Dolores A. Ballesteros
Superintendent'i
Fee collected /exempted by Pauline Pearson Payment Received $3.340.24
Check No. 101043
Signature Rv k 1 u'A Q \ r. o ckI A�1 A,i
�e
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