9606-091 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty.o'f..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'
i t-
Daw, Signature of Cont.ac or—
OWNER-BUILDER DECLARATION
I h6re'by affirm under penalty of perjury that I am exempt from the Contractor's
License Lavifor the following reason: 1 11 . . - :1 - . , . , I
( ) 1, as owner of the property, or my employeds 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).
1, as owner of the property, am exclusively `contracting g wi Ii icensed
contractors TO 061)9VUdt the,project,'(Sec. .7044, Business, 9, Professionais
Code)..
O I am exempt.under Section.--- B&P.' fo*r this reason,'
Date •Signatur& of Own6r,1
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-in'sure fo . r, workers'
� - a
compensation,'as provided f8r by Section -3700 of the L'bor Code, for, the
performance of the work for Which this permit is issued'
lhave and will maintain workers' compensation.. insurance, as required by
Section 3700 of the Labor Code, for the .performance "of -the Work, for, whichjtii_s
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 1,should become
subject t?,the workers' compensation provisions or Section 3700 of the Labor
Code, 1,shall forthwith comply with.
those'provisions.
Date,;`�V-01'je-` Applicant l"'
TT
'low
.Warning: Failure to secure Workers' Compensation coverage is unlawful"96d
,.'shall subject an erfiployerto 'criminal penalties and•civil fines.up4o-fibo,doo, in
additioii to the cost ofbompensatic'n, 6mages, asprovided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Appli6ation'is hereby made to the Dirbctor'of Building and Safety
for a permit subj6ct to the conditions 'and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made -9 each'person at
work
Whose request and for whose benefit wok is, performed under'6r pursuant to
any permit issued as a result of this applicaton agrees. to, & shall,,. indemnity
& 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 -c,ancellation..
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 building
construction, and hereby authorize represgritatives of this City to enter upon
the above-mentioned property for inspection purposes
rR
I signature (Owner/Agent)
BUILDING PERMIT PERMIT# CONTROL# -
35415
DATE VALUATION LOT.,. TRACT
r
i'361_1
JOB SITErN
ADDRESS . 4-
7195 VKAXIT COURT ,
4i" 34MI.
,OWNER
CONTRACTOR DESIGNER ENGINEER
NJIVICY4
4,vi,
"W"I
0i K:�:la 1.:+11 . JU
-m _r, STE. 4100
. 1 1.
,,-,AN 6kR.'NAK01_N, C'A 01409,
S
SAN Fik."fARDIN( (,,4 A. 97408
811 W07
USE OF PERMIT
"A 921"15
00+ . Ru"Y iffl, LA QIJUN',VA NeUt
PI AN zxrmy
LION W
('4A RAQ1YC7.AA,P0R3* 4 1100 SF
11 -AN fl- t EC"f Z, F 17 P
AI Aiii64-fiR
KMIX, rQR. I- FiFis 2.23-000-44 3-342 P,ttfo.vl
-
'MU" TION ID N F.W
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53,
IgCy(%
By
RECEIPT ,--I
DATEJ 'T
1BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings
Ducts
Slab Grade 17 1 A7Return
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap jj
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
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
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:
-
Desert Sands Unified School District
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be.Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/19/96 APN # 604-343-023 '
No. 14616 Jurisdiction La Quints
•
Owner Name Century Crowell Communities Pprmit #
No. 79195 Street Violet Ct. Log #
City La Quinta zip 92253.. Stud; Area 230
Tract # 25363-1 Lot # 42 Square Footage 14611
'Type of Development_ Single Family Residence No. of Units 1
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 zccessory 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 - 1,461 or $ 2,688.24 r
the property listed above and that building permits and/or Certificates of Occupancy for,
this square footage in this proposedproject 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 $2;688.24
Check No. 28118
Signature l�.al&i Qon�o �a AA n;0 cyv`-- .
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