9803-120 (SFD)r 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
101lr
Date:�U Signature of Contraeto �Y r
OWNER -BUILDER DECLARATION
(.hereby affirm under penalty of perjury that I am exempt from the Contractor's -
License Law for the following reason:
( )
1; -as' -owner of the property, or my employees witn 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): ;.
O 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.
(j I. have and will maintain workers' compensation insurance,.as required by
SePtion 3700. of the Labor Code, for the performance of the work for whicfi this
permit is issued. My workers' compensation insurance carrier & policy no. are:.
,Carrier Policy No.
(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 provisions of Se Ion 700 of the Labor
,Code I sh, fi forth th omply with�bese,pr visions/
date: / pplicant
-
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. �t
.1. Each person upon whose behalf this application is made & each person of `
whose request and for whose benefit workis performed under or pursuant t.."',3
any permit issued as a result of this applicaton agrees to, & shall,.indemnify
r & 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 ao cancellation .
I certify that l have read this application and state that the above informationis
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize repre§§entatives of this City. to 'enter upon
ond�.-•l
tn;the above-mentirposes
YT f
f,Slgnature (Owner/Ageni Date
PERMIT# *t CONTROL# ;
BUILDING PERMIT
DATE VALUATION LOT-, TRACT �? rt ;
590.4,111. t1 ; 4 .
JOB SIT , v,.�-•�'7r :-. '61p.,
ADDRESS -d6 �'iS �: _ ���� w. '- .
APN
60
r
OWNER
CONTRACTOR / DESIGNER / ENGINEER'
C ;�i'!"u?P.Y CID
CEN.,RJWY t::E'O141P-i 5 co IN14 JN'1Ti
1535 80: °.Y.7" :9,r..F ,S11'a. 4200
SAN ,BE)KA13DiN r '' C,,k 92409.
S1kN 13 '.. 1VAkD1Nra' CA 92403 . -
(909)3R1 -5t04:. ' ><;.'8l.ft, 2120
USE OF
��PERMIT
KA1v 2AR r SE0 - Oil Sul .•lh f 1..A. A t�CiRTE - 4 V-5 K, AN 1214 'X
�ti.�1.�t14.,1 Lt3�. r1,1�1�'1:kP:ii . ' ` - • •
4.RAL T C(:YNS RUC'.l'* - 1.244:90 Sr. -
1O.R.i % PATIO 36.00.:31' '
Ga�5LA0110'AtLk'F ti`P 6240.0 Sig
:?LA14 CHECK.FQ 101,400419-319
t'w.°tNST R C -f V N� f F. I.f1.1�11fk4 i 3-114Ii1 � 3�,(,t)
1ti�aCl,t�l1�:�..,"'£�° � 1t�1�!?t7t)-•��:eflUt)'' ' ��7.0G�
- .
i?115"172Y� �.: f 4E ":1U.3 �ti{1 42(i•f}i0 S104Af1••
l:a. tMf31%Ft,P FL4ls 101-000410-0W,.'1t! 14 t1C►
cTNc;1ti<it?7'IGN f'1_F, f<,! til? .1,U4 LKwi-�,::1 di(tt? :, 5f3 94
fi;l;r'�.11�G 1=,1;'�e 1Ck �C1i . 3_00,0,
•,.N`i?12:f�;ri'i�u�i'17g2;1✓;1'L� . :. � '. ��,� �� 3�,s:. . ' ��.%+>�,,31
•
PLAN C'Ii C�jti }�81Y :1t?.i WO- It 3+£3. 434, 64 `
'yvl,fli^,.tti.✓£i2ip. ,C�.Ji9 ��i ll �Y ."!,d�' ''�11.aP S.'CK'
$3,11,41. 1
.if-`i«V ,L:?S.tY
I.LxS 1MO FS,l IS
`ab47.ci=1 -• -
$2, 76652
RECEIPT , -; i
DATE `-+ +. `
BYA
DATE FIN ALED
INSPECTOR z±,
OPERATION
DATE
INSPECTOR
OPERATION
DATE 7
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Q
Underground Ducts
Forms & Footings
(
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
p _
Exhaust Fans
0. K. to Wrap
ZZ=
F.A.U.
Framing
/,,2•- S'— q,
Compressor
Insulation
L _ -_,TV
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Z 2 ¢ y
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
6 e�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�6 .Q
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:
R Desert Sands Unified School District
v47-950 Dune `Pa1m0Road'
,Notice:' La Quinta, CA 92253
Document Cannot Be Duplicated .760-771-8515
CERTIFICATE OF COMPLIANCE:
Date ,:7/22/98. APN # 604-373-003.
No. 1'7376 Jurisdiction" La Quints .'
OwnerNameCentury Crowell Communities k
r Permit #
No. 79=085' Street Victoria Drive ` y Log #
t City La Quints Zip " 92253 " r Study Area ;.
- 1,245 ' t Tract # Lot # Square'Footage
:Type of DevelopmentSingle Family Residence �' Ivo. of Units 1 ;
At.Ithepresent time,, the Desert`Sands Unified School District does riot collect fees,on garages/carports, covered
patios/walkways, residential additions uor replacement mobilehomes.
der 500 square feet, detached accessory structures
It has'-been`determined the above=named owner is exempt, from paying school fees at this time due to the following "
reason: ., i ; . ;..
J {~++ •,. .. t '+ .. ..�� ,'r ,'n� rte
EXEMPTION NOT'APPLICABLE
This certifies that school facility fees imposed pursuant toi Government,Code 53080•, in theamount of r .;
1.93 X ,11245' or $ 2,402.85. b r
the property listed above and.that buildmg"t
permits and/or Certificates of Occupancy for this square footage in,this proposed prpolect may now be lssued,� f
fit..
Fees Paid By CC/Foothill Independent Bank/Ed Knight. . i T - t:
g • ' �� r�Telepho e' 909=381-041
Name on the check
i By Dr.; Doris Wilson . 6f 4 M,
Superintendent.^
Fee collected /exempted by ; Juanita Green Y .; Payment Received, $2,402`85 t
Qheck,No 604539
Signature
NOTICE: Pursuant otAss bly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90�ay approval period in which you may protest the fees or other payment idem ed ,
t ' above will begin to run fro the date 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 4o
collect them on the District('s)(s') behalf, whichever is earlier. f . a
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
• 'fir". .. ... . - i v ' ' • I i 1 _