9803-121 (SFD)LICENSED CONTRACTOR DECLARATION
+!:-=
I hereby affirm under penalty of perjury that I am licensed under provisions of
Hr . Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
w W `Professionals Code, and my License is.in full force and effect. '
O =) co License # Lic: Class Exp. Date
L It- dLO/
Ko Z 1]Date r. Signature. of Cont.ac� for +//
CDO�
I . J U "' --` OWNER -BUILDER DECLARATIO
I ~ .W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
h,,a License Law for the following reason:
U
Z_ ( ) 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
iwith licensed
contractors to construct, the project (Sec. 7044, Business VP.rofessionals
Code).'
i C O I am exempt under Section B&P.C. for this reason
N Date Signature of Owner '
WORKER'S COMPENSATION DECLARATION
.1 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.
(y) 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.
• ',x'1~%1; H f"3S. t�'t?. Z,tw2s�',SSir►
(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 wor ers' compensati rovisW.M of Section 3700,of the Labor
C�'ode,>I� h'll forth iiF -comply with..those vise . ns.
,Date:, // �`pplicant _�' V0
Warning: Failure to secure Workers' Compen Ion 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. n o
1. Each person upon whose behalf this application is made & each person at f
whose request and for whose benefit work is performed under or pursuant toz
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 candellatloh w
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.puilding'.`
copstruction, and hereby authorize representayyves of this City to enter upon
the above-mentioned property for in •i ection pulpo es.. /
(-,._._.. f .d 'yam.✓ / -�
hSignature (Owner/Agent)' / �^ Date'*�%5
- .ry.uw..• +B.
PERMIT#a
BUILDING PERMIT CONTRO�N
.i�.413�!
DATE ' VALUATION LOT;TRACT
-i 4
:��-y----,�a
L
JOB SITE
APN
[ta�
ADDRESS %7 :�, �.g TE}.JS 8�1•-.-•��T.B-1�
'OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY-CRO�p�s�{;%�'+iry:•i,�CO}+L•r.[,LI�t/U}� MES
C4�1`•1'iUR.YCROS��I3i�LL�C,t7y�(�a1(�MU�'+�MIES
1.535. SO. ".1)" SI fc„C�J' , pI.MGr :7'7117
1a�l SO. "Ll" SMEEr, ,'�, T, 7T.•00,
SHIN B RNARDWO CA .92=105
BERNARDIR.O GA 92,108
004}381-600 CBLO 2120.
USE OF PERMIT
PLAN C - :; D - DrL RjCY At L:4 Q l a .A.1.ORTE, - °,10` 5 t LAN CR'FCK
RED14 ri®rf APPL.IEM -
'i`t2AC-T CONSTRUCTION 1,445,00V
GAP_kG C'ARF110RT 05.00. SF
WSTIM ED tv`D.SS"i OF L"ONaYTR'UC 111:1° ,
PERMIT FEE SUMMARY
PLAN CHECK ITX, 10.1.:000-439>318 5504.98
COl+J3'I'.kUcclol'i Ftf: 101-00,0418-000 $599.00
*s"CH,P1I11:Cc`V FFE 111-000-421.000
1 LEC'1'RICAL RKE -101-000420.000
PLUMBING FEE 101-000-419-000 $148;00
S17RONG WTION FEE - RES1t J 10-Q..W2.41-000 $9,0
GRIAOING FES 101 -000423 -OW $20.00
INFRAS:P.RUC"Iti"3tsr RISE 225-004113-.342 $2,045.46
PLAN. FFB 101 7-430-3.1s -$378:'7'3
V.
r
guwrorrAL,co"�'1f 1GI°IQN A2vC� MANCH'1?(�1s3,�ri,.31
LL8w. >tifZE PA!D !/1 t 5
•$378.73
TOTAL SPERM. '1 'FEF DUE NOW
'� ��-_'
RECEIPT ° •—DATE"
-"A?
By/ i
DATE FINALED
INSPECTOR
-_ Q• a .. .s [.; � {
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
T INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
! O Q
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
z 2--(-7- Qy
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- (o
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-8 —
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law 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
477950 Dune Palms Road ,
v Notice: La Quintal CA 92253
Document Cannot'Be Duplicated 760-771-8515'
CERTIFICATE OF COMPLIANCE , x
bate., 7/22/98APN # 604-373-004
-No.' 17377 r c Jurisdiction La Quinta ).
owner NameCentury Crowell Communities "
Permit #
N0.170-105 Street Victoria'Drive, -Log # a
cityLaQuinta ,zip -,92253 Study Area
q g
Tract #. F f Lot # r Square Footage
Type of Development Single Family. Residence - No. of Units 1
r".
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.
r It has been determined the above=named owner is exempt from paying school fees at this time due to the following
reason: r a
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to' Government Code 53080 `m;the amount of
aFP ' 1.93 X 1,445 or $ 2,788.85 the property listed above and that bmilding
•'K d,
• permits and/or Certifcates of Occupancy for this square:footage in this.proposed project may now be'issued
Fees Paid B CC/Foothill Independent Bank/Ed Knight,,! �� " x"1909 381 0041,
By P g, X6ephone
- Name on the. check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by "Juanita Green ' s Payment -Received $2,7$8.$$
... e — i
Check No. 604539 ,
Signature
` r Pursuant of As mbly 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 or other payment ident�ed
above will begin to run 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
[NOTICE:
ollect them on the District(
Collector:
whichever is earlier.
Collector: Attacha copy of county or city plan check application form to district copy for all waivers. 4,,
Embossed Original- Building Dept./Applicant; Copy - Applicant/Receipt Copy - Accounting