9803-118 (SFD)LICENSED CONTRACTOR DECLARATION
1 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 forceand effect.
License # Lic. Class Exp. Date
Zile,/
Signature of Contractor
OWNER -BUILDER DECLARATI N
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:
Cartier Policy No.
d.�;� 11117 I S, C'.t i'.
(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 pro anions of Se tion 3700 of the Labor
Code, I I foJ,�.hwh comply w't _ os Provn
�atel� Applicant '
Warning: Failure to secure Workers' Compen ~tion 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 fo. inspeecctiurposes.
V gnature (Owner/Agenr�-: l -p ate•/ Date/
PERMIT #
BUILDING PERMIT
91,44113-113
DATE %J ,yqg VALUATION SIM-767AII) LOT 33 TRACT 217990
JOB SITE d
ADDRESS 9-04 -5 4'ii.1.OR1:A Qil:��iw
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
0'PG 411'+d r) 4' F3da4+:r't i f'�N'1 �I%H tb1'!r! f:JC
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.SA -N R't MAR INO C.A. 92,108
SAN BERNAREANO CA. 92408
USE OF PERMIT
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AF(T fN P4i9JX—,'.P1,.Ar';E v kt #f;"i4J.-OCIi)- 55:f)ilt9 $41J)2
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TO TAI.,YERNOT FE'EN 01M, NOW
Y7
ai
S
.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
i
!w
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING PPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade —
Return Air
Steel
Combustion Air
Roof Deck o
Exhaust Fans
O.K to Wrap
F.A.U.
Framing / -Cs
Compressor
Insulation L -N --@Y
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath -
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROV S
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 - /6 -4
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 16 _
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)
i°� �' r• Desert Sands Unified School District
47-950 Dune Palms Road
Notice. .0 1 La Quinta, ;CA 92253
Document Cannot Be_'Duplicated. { _ 760-771-8515.
CERTIFICATE OF COMPLIANCE,
Date 7/22/98 APN # .604-373-001
No. 17374 "` Jurisdiction La Quinta
Owner NameCentury ;Crowell CommuPermit
nities ` ' w , r.. i`.
" -v .#
No. 79=045 Street ' Victoria Drive . Log #'
City La Quints zip' 92253 Study Area
Tract # r '� " .Lot # _ �_ Square Footage 2,010
Tract r t `
Type of DevelopQnent Single Family Residence No; of Units 1' '
r,
At the present time, the Desert Sands. Unified • School District does not colleci fees ;on garages/carports, covered
patios/walkwiys; 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: r
{ EXEMPTION NOT APPLICABLE
�. t , A
This certifies that'school facility fees imposed'pursuant to, Government Code 53080 in the amount of ► '�� • .
• ` ,1.93. � `X 2,010 � or $' 3,879.30t , •-..
> .1 the property listed above�and thatbid'ildmg 6-
permits and/or Certificates of Occupancy for this square footage in this proposed project may now beQissued
teT,r
Fees Paid B CC/Foothill Independent Bank/Ed Knight Y.`�'"
, y . � h
P $� ." Telephane 909 38:__����-0041
Name on the check.
By. Dr. Doris Wilson -
'Superintendent,
Fr •. A' z
Fee collected '/exempied,by' r Juanita Green Payment Received , . ` $3;879.30 .�
� - . r �' •-tel ,. ..}i - s. Y'. ",� 4. • 13�.,�:s^
604539
Check No.
Signature
NOTICE:, Pursuant of Asse ly Bill 3681 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
will begin to run from he date on which the building or installation permit for this project is sssued or on which they are paid to the Districts) or to another public entity authorized to
r collect them on the District('s)(s') behalf, whictiever is earlier.
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