9606-089 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby'affirm under penalty of perlury'`that I am l'icens'ed under provisions of '
,r0hapter 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. Classes,! ` Exp. Date
rte �r}n � � 1,1 ,r�% .^"''c. �U��'t !•
Date % r!l ~ Signature'of Contractor::'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat 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,`Businessr&,•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..tfie 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 theperformance of the work for which `this
'permit is issued. My workers' compensation insurance carrier. & policy no: are:
Carrier t Policy.No. ;
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the work for which this permit is issued'
I shall not employ any person in any manner-soo aPto become subject to the
Workers' compensation laws of California andagree that it I should become'
subject to,,the workers' compensation provisions of Section 3700 ofAhir;5<11
r
Code,:. hall forthwith comply with,those provisiohs. ✓,, %__/'
Date' �' Applicant'
Warning4ailure to secure`Workers' Compensation-cov.-erage is unlawful and
shall subject an employer to criminal penalFies°and civil fines up t6.$1 60,000, 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.requ est 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
hcertify that I have read this application`and state_4hat 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 f�or*inspection purposes''�M `
• may` `h.�•,;!l,�fr�. .
`Signature (Owner%Agerit) -" �' Date
• .BUILDING PERMIT ' PERMIT# • ;. '. CONTROL #
.3543-
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RECEIPT%!' �—
DATE_
BYDATE
FINALED
INSPECTOR
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade f.,
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L. 61 7
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWAL PP14OVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral4 V4
Pool Cover
Sewer Connection 4rl ft 7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
t
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)
' Desert Sands Unified School District
Notice• 82-879 Highway 111
• Indio, CA 92201 -
Document Cannot Be Duplicated. 619-775-3500 '
of
CERTIFICATE OF COMPLIANCE
Date 6/19/96 t APN # 604-343-021
No. 14614 Jurisdiction La Quini.a d
Owner Name, Century Crowell Communities Permit #
No. 79180 Street Violet Ct: Log #
City La Qunta zip. 92253. Study Area 2301
Tract it 25363-1 Lot # 40 }Square Footage 1663 "
----------------
Type of Development SingleFamilyResidence 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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.84 x 1,663 or $ 3,059.92
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 By Foothill Independenf Bank Telephor_e 360-7464
Name on the check. `n
By Dolores A. Ballesteros'
Superintendent
4T'
Fee collected /exempted by. Pauline Pearson Payment Received `$3,059.92
Check No.. 281,18 a
Signature p
g Ola. A � X 1-/% A 9 . c 0 ,QLI /1 A ,(a/Yl
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