9606-088 (SFD)LICENSED CONTRACTOR DECLARATION''
ITMhereby affirm under penalty of perjury that I am kensed 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 # Lia Class y;'� , _Exp. Date
Date �' r ' �' Signature of'Contractor �-�•-^'� ' e
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of;perjurythat I am exempt from the Contractor's
License Law for the following reason:
(.) 1, as owner of the property; or my employees with wages as their sole
compensation, will do the work,'and the structure isnot intended or'offe'red for
sale (Sec. 7044, Business & Professionals Code).
( .) 1 :as owner of the' property,_,am exclusively contractmq with IICeIISed
contractors to construct the" project (Sec. 7044, Business & 'Professionals .
Code).
O Lam exempt under Section t B&P.C. for this reason
Date " Signature. Owner,
Yy
WORKER'S COMPENSATION DECLARATION `
I hereby affirm under, penalty ,ofi perjury one of, he following declarations:.
( )• I have,and will malntain'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 Whichthis
permit is issued. My'workers' compensation insurance carrier & policy no..are:
Carrier : Policy No.
ZZN).1' E IN.5. 60
(This section need not be completed if the permitvaluatiori'is fob $100.00 or less).
( ), I certify that inthe'performarice of the work for which this permit is issued,
I shall not employ any person in'any manners as to become subject to the
workers' compensation laws of California�and agree that. if I should_ become
Subject to tqe workers' compensation-6rvisions,of Section '3700-ofahe Labor
Code, Ish 11 fort'with comply with Those .provisions.,-'""_ .--� � ,,.,•�
Dat APPllcani ✓'`�'"'�� '-~ a'-�'-"`.
Warning: Failure to secure- Workers Compensation coverage-isrunlawful and
ci
shall subject an,employer to criminal penalties<and v hi en 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 ori 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.
& 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
I certify that I have read this application and'§tate that,the above information is
correct. I agree.to comply with all City,ndState laws relating to the building
construction, and hereby authorize representatives of this City to enter, upon
the above-mentioned property�lfo`r:inspeetion purposes
Signature. (Owner/Agent)
. � BUILDING PERMIT � PERMIT# • ..._ CONTROL
3542
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RECEIPT:
DATE
BY
DATE FINALED
INSPECTOR
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. rGrills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail 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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water PipingPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection t7 4
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) ,
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
Utility Notice (Perm) ,
COMMENTS:
-
Desert -Sands Unified School District
Notice: 82-879 Highway Ill
Indio, CA 92201, „
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/19/96 APN # 604-343-020 4'
No..'
o. 14613 Jurisdiction La Quinia
Owner Name Century Crowell Communities Permit #
No. 79190 Street Violet Ct. Log #
City La Quinta zip 92253 Study. Area 230
Tract # 25363-1 Lot # 39 Square Footage 166
Type of Development Single Family Residence No. of Units 1 `
Comments
a
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 Independent Bank -Topaz Telephone -360-7464
Name on the check...
By Dolores A. Ballesterosa
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $3,059.92
Check No. 28118
Signature Pl t �.Q¢�_o (< ➢ Ptel �'` .
Collector: Attach a copy of county or city plan check application form to district copy for all wE.ivers.
Embossed Original- Building'Dept./Applicant Copy - Applicant/Receipt Copy - Accounting '