9606-090 (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 effecter ,-,
License# Lic.Class !' fExp. Date
Dater✓ Signature of Co/ntractor.
OWNER-BUILDER'DECLARATI ON _ >
I hereby affirm under penalty'Df perjury .that l am exempt from -the Contractor's
License Law for the following reason: 1
( ) 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'propertX', am exclusively contractinp'with •licenged
`contractors to `eon§truct:the project (Sec. 7044;• Business, &" Professionals
Code).
O I am exempt under Section" B&P.C. for this reason'
Date '- "�'Signature of Ownerb.
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:
CarrierPolicy No.
r,.tsNff* fR Y14 . %X)_ . • I 'Ali, ti(3c +�ii'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 thg6f-1 should become,
subject to the workers' compensation provisions of -Section 3700,of,the,Labor,,-
Code, I shall fo +hwith comply with those provlsl s-�,',,
Date' !'`-„'� .r% Applicant
Warning: Failure to secure Worker"s' Compensation coverage Is unlawfuland
shall subject an employe"r'tciminal penalties and blvd -fines -up of $100,000, in
addition to the cost of compensation, damages as=p_o ed for in Section 3706
of the Labor Code, interest and attorney's fees. r
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 r
& hold harmless the City of La Quinta, its officers, agents and 'employees.. U
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 6uildirig y
construction, and hereby authorize rep"resentative's of thjsfCity to enter upon
the above-mentioned property for inspection purposes.'''`
Si nature (Owner/Anent) - -'� a r' � �f y Date" . ./
BUILDING PERMIT PERMI `# ^ CONTROL#
3544
DATE VALUATION LOTTRACT
l X41 16.76T40 961-1 ptP
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JOB'SITE
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ADDESS
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OWNER
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USE OF PERMIT
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SA 76.63
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
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
POOLS - SPAS
BLOCKWALL
PPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
F
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
E fEquipment
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 114
ELECTRICAL APPROVALS
Temp. Power Pole -
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final ZAK
Utility Notice (Perm)
Desert Sands Unified School District
Notice:' 1 82-879 Highway 111 =
' Indio, ,CA 92201 -
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/19/96 APN # - 604-343-022
Nor 14615 Jurisdiction . La Quinta -
Owner Name Century Crowell Communities - Permit #
No. 79185 Street Violet Qt Log # '
City La Quinta Zip .92253 Study Area 230
Tract # 25363-1 Lot # 41 Square Footage 201C
Type of Development Single Family Residence 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 k
This certifies that school facility fees imposed pursuant to
Government Code 53080 x
in the amount of 1.84 X 2,010 or $3,698.40
t 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 Independent Bank -Topaz Telephone 360-7464
Name on the check
By Dolores A. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received' $3,698.40
Check No: 28118
Signature p PQ LA L6�L�
� to PynnO -
Collector: Attach a copy of county or city plan check application form to district copy for all wiLivers. ,
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt. Copy - Accounting