9803-119 (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
i.t 41 s£t n l.o 3ls9
,`'� a
yDate' � - Signature of Contractors
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 isnot 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).
O I am exempt under Section B&P.C. fo`r this reason
Date Signature of Owner ^
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:.
O 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 Policy No.
Z1 N1"N INS. CQ. Z04=902
(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,
(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: Se tion 3700 of the Labor
06de!I shall fo Kwit comply with t 9!e io�l��
,Date: �� �� Applicant s
Warn g: Failure to secure Workers' Compensa n'coverage is unlawful and
shall subject an employer to criminal penalties ard.giyil-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.. Utz
1. Each person upon whose behalf this application is made & each person at P_
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`,f
& 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 voiclM
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 s -
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 opinsp�on purposes.
`Signature (Owner/Ag nt)' ' Date_
_
PERMIT# C°NTR° • ; `
BUILDING PERMIT `"
DATE VALUATION LOT � "`�+••-..-.. .• TRACT .
..
34
JOB SITE` _
ADDRESS��S&yWY i'
APN
�q
S��••�%.4-�7V•
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C F SCI'i UR'�T+G1 R`U+yt�VLE�aI�7.+L C�Xc2LA�l1A+r�iAif)tl�i'�`1'ES
�FN1�`iClT�fti't�Cl2�.ryOWlWELL Ct•11�,k.c:C��ftf����NITIE. •
1535 ` O. -D !~J R.GET, SIE 200.
5J35'SO. "D" S l..RF.91*, STE. #200
SAN BERNA2PINC) CA 92.408
SAN BERNARDINO . CA, 92408
(909)481-60 -7 C F3L#1 .2120
•-
USE OF PERMIT - -
PLM4 3B - SFf) -DEL MU AT LA: .(3-s, -) a ik tSU t;TF? - 5,0,75 PLXN CRMO
REDUCTION A:P.P[.•CU.
e
{
7RAC'T CON' Ti RUQ `1'1ON 1;445.00 8):
GIARAOEICA"ORT 633.00 S['
r
UST .1MAT4CD C' 0 VT OF C ON S TR UICf1Or*4`
4304,909» 13-
.
PERMI'T FEE SUMMARY'
PLAN C'14ECK. FM 101-000-439-318 5504.98
CO'NSTI2UCTION FFE, ` 101-000-418-000 $599.00
M•C1' ,ANICAL FEE 101=000-421-000 $47.00
,
ELEC'17RICAL FEM 1.01-000420-000
PLUMEfNG FEE 101-000--119-000 $148.60
S971EONG MOT LON f Ec, -.SID 101-000-241-000 $0.09
GIUkOING FES 1.01-000-42:3-000 $20.00
k�ASIle11111N,443342 $2,0-5.46
PLAN CH:I:(,I;.1 .101 t)ij0•339-31$-$:9YP...73
- ro' n k>
�"L�33 ',!tfr.aL E ONS' U.C'•1 kE)N AND MAN CHECK
$ 3;,1E1 .3!
' p � LESS' 1K&PAID F.EE11
�.
_... _; _118.73
TOTtk <r PER11'4`itT FE,.F:5 DU'ENO-�4'
b:i,4(ll�s:;5bl
Air a S
. . •awl'
RECEIPT
DATE 4
BY /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
e7
Underground Ducts
Forms &Footings
7�
Ducts
Slab Grade
—
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
2,
F.A.U.
Framing
/2— / S— fr
Compressor
Insulation
/y - _ Qy
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/,2
Drywall - Int. Lath
I.X-1 Z3 joy-
I
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
q- 6
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 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
t
t
Final n
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District -
477950 Dune Palms Road Viz,
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515 ,!
I
CERTIFICATE OF COMPLIANCE
Date 7/22/98 APN # 604-373-002 ,
No. 17375 Jurisdietion La Quints
+,
t r owner NameCenturyCrowell Communities Permit #
-'
No. 79-065 Street. Victoria'Drive Log#
City La Quints - Zips, 92253 Study Area
' Tract #' J Lot # F Square Footage ?1,445 r-
Type of Development Single Family Residence
No. of Units 1
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 mobilefiomes. -
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 imposedpursuant to, Government Code 53080, in the amount of
1.93 X 1,445 ' or $ 2,788.85 the property listed above and that bldmg-1.
permits and/or Certificates of Occupancy for this square footage in this proposed project may now .be fssue'd,
Fees Paid By CC/Foothill Independent Bank d Knight j Teleph e 909-381 0041
` a
Tiw _°
t Name on the check
't
By Dr. Doris Wilson
- Superintendent 'cF YYY.1"lll
;Fee collected/exempted by Juanita Green Payment Received $2;788.85
Check No. 604539
'Signature
NOTICE: pursuant o sserimbly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees of -other payment identified ;
above will begin to ruK from the dale on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to t
tolled them on the District('s)(s') behalf, whichever 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
4, °.