9606-092 (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 •a d
Professionals Code, and my License is in full force and effect—, .. '
License # ;- Lic. Class = �, a` ,,Exp Date r
Date' Signature of Contractor
f .
OWN ER-BUILDEWaCLARATIO,N%'
I hereby affirm under penalty of perjury that 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).
( ) 1, as owner of-.the"property, amexclusively contracting With =licensed
contractors to constrdct,`the project (Sec. 7044,,.Business & Professionals
Code). x:
( ). I am exempt under Section>•' ' B&P.C. for this reason
Date %Signature, of. Owner
.WORKER'S COMPENSATION DECLARATION
I hereby 'affirm- undei` enalty,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 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 Irlt'1'3:3 f ld.ia Vii/. `i •,,,�` • .. pit iiurytii
(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.be(5'me subject.to the
workers' compensation laws of California,.andd agree that'°if I should becom
subject to the workers' compensation provlslons of,Section^3700 of,the Labor_
Code, I s h all f ghwith comply with those.provlslori
Datp-- Applicants'
Warning: Failure to secure Workers' Compensation -coverage Is unlawful and
shall subject an employer io criminal penalties•and civil Jines 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 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, in
& 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 andState laws relating to the -building
construction, and hereby authorize represe<ntatives of this City to enter upon
the above-mentioned property for, inspection purposes.. r
Signature (Owrier/Agent) • -r -�' -�'` Date z
BU�L��NG PERMIT., PERMITk -., .'' CONTROL#
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DATE' ALUATION -LOT: TRACT.
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JOB S Y
APN
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OWNER
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CONTRACTOR / DESIGNER / ENGINEER
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SAN BEts'Nf1fL.DINO C.A 92408 '
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USE OF PERMIT
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1''E RMI AT S+'Er SUMMARY'
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' 1y�- ^•i 1 r ..�,�i�i fi.� �.dJW 3.1VJ.v .1�i,lV,�../ PL.I IN Clic, Clic
i, ti,S %'E -PAID CF.EMS .
$0.01) .
ON
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings t17 JVI
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 I 1444::W6POOLS
BLOCKWALL P OVALS
- 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 f
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping I
Gas Test
Appliances
i
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
ExterW 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 # 604-343-024
No.' 14617 _ Jurisdiction La Quinta
Owner Name Century Crowell Communities Permit #
No. 79205 Street Violet Ct_ Log #
-City La Quints Zip 92253 Study Area 230
Tract # 25363=11, Lot '# 43 Square Footage 1663.
.Type of Development"- Single Family Residence a No. of Units P .
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
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 Telephcne 360-7464
Name on the check
By Dolores A. Ballesteros,.
Superintendent ;
Fee collected /exempted by Pauline Pearson Payment Received -.$3;059.92
Check No. 28118
Signature
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, '