9606-087 (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 effect. ,r
License # CCLgyic. Class r " r/Exp. Date
'# lip's ,or, •rr '.,.,�y„7u�.1..�' ••~
Date,!'�� �t✓" Signature of Contr o-
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OWNERTBUIL'DER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors.
License Law for the following reason: v�
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 lirensed
contractors to construct 'the project (Sec. 7044 Business &• Professionals
Code). '. J, t,,
O I am exempt under Section•' B&P.C. foor.this reason
Date-SOnature of Owner'
WORKER'S COMPENSATION DECLARATION
I hereby affirm- under pe alty, 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 `3706 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 n.o. are:
Carrier Policy No.
itrf. � { E l.t .6 t<4'j, �'i;,i. ' s';1 �^!`aJ,4i�?i�U 1 � •
(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 sods to become subject to the
workers' compensation laws of California -,,and agree.that if I should+become
subject to the workers' compensation.provisions,of"Section 3706'&i the Labor
Code, j shall foJJrthwith comply with those p�rovis`ions.
Date:��'`%`7/651'Applicant' %%" ;«°"/�^�w-�^ �' • ��"--
Warning: Failure to secure :Wo kers Cnompensatiocoverage Is unlawful and
shall subject an employee to criminal penalties and civilfines up to $100,000, in .r
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 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 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 representatiyes of this,City to enter bpon
the above-mentioned propertyfor-insppecUon 01 rposes ''
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Signature (Owner/Agent)`=`—+ '""�•" Dat(_
BUILDING PERIIIIIT PERMIT# CONTROL#
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BY
RECEIPT
I 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.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL AP ROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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 lt4
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 za
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 j APN # , 604-343-019 .
No. 14612- - Jurisdiction La Quinta
Owner Name Century Crowell Communities Permit #
` No. 79200 Street Violet Ct. Log #
City La Quinta zip 92253 Study Area .230
Tract # 25363.-1 Lot # 38 Square Footage 1461
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` i�- 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 Coce 53080
in the amount of 1.84 x 1,461 or $2,688.24 t
the property listed above and that building permits and/or Certificates of Occu-3ancy for
this square footage in this proposed project may now be issued. -
-Fees Paid By Foothill Independent Bank -Topaz Telephore 360-7464
Name on the check,
By Dolores A. Ballesteros 4
Superintendent
Fee collected /exempted by Pauline PearsonPayment Received $2,688.24
Check No: 28118
Signature 2,Ai Aa "
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