9606-086 (SFD)LICENSED CONTRACTOR DECLARATION'
4i hereby'affirm under penalty of,perjury tKat I am licensed Under provisions'of
Chapter 9 (commencing with Section 7000) of Division 8 6f.the Business and
Professionals Code, and my License is in full force and effect.
-
License # Lia Class Exp.Date
5�
Signature of rnntmrtt4
i Dal- r
OWNER -BUILDER DEC LATION
I hereby affirm under penalty of; perjury that I am exemp0romthe Contract6r!s
License Law for the following reason:
1, as owner of the propertyi.or my employees withwagesas•thbir sole
compensation, will do the work, and the structure is not intended -or offered for
sale (Sec. 7044, Business & Professionals I Code).
prope
1, as owner- of the ' rty, am-excluisively contracting :with licensed
-contractors to. construct the'project (Sec. 7044, 'Business..& Professionals
Code).'
O I . am exempt unclerSktionv . B&P.C. for this reason" son
-Signature,
Date of Owner
WORKER'S COMPENSATION DECLARATION
III hereby affirm. I have anunder; penalty ' of perjury one, of the. following declarations:
will mainta'iK a., certificate of consent to self -insure for workers'
compensation,7as, Provided for,. by., Section3700 of the Labor Code, for tP6
performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance,, as required by
Sectiori.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:
T
Carrier Policy No.
Its it'Th ims- "; 5,
(This section need not be completed if th6:permit valuation is for'$1 00.00 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't`6 become subject to the
workers' compensation laws of California-,4n'd—'agreet6t if I shodId become
subjectto thg workers' com pen sationprovisions,ofSection, 3700 of the.Lab6r
Codej.. shSILforInwith comply with,th se provisions:
Warning:, Failure to securewWdirkefs Compensatti�6� �Cerd§—e is Unlawful and
shall subject an employer to criminal penalties, -a"nRivil fines up to $100,000, in
addition to the cost of compensation,- clarrfages 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 b6half this application is made'& each person at
whose request and for whose 6en6fit work is performed under or pursuant to
any permit issued as a result'of"this applicaton agrees to, & shall, indemnify
,& hold harmless the Cityof 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 diys from date of issuance ovs6cli
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 agr6e to comply with all City,,and Staie'Iaws relating'to the building,'
construction,'and hereby authorize iepresentatives of this,Cityio.ehter upon
the above-mentioned property for. inspection 'purpo-i'e's'�'rl-'.'*�"--.
Signature (Owner/AnontY
BUILDING PERMIT PERMIT# CONTROL#
10606-086,
'LOT'
DATE VALUATION TRACT'3540
S90t474A0 .47 NO
q(.2
:-
JOBSITE,
ADDRESS
JAPN
,OWNER
CONTRACTOR DESIGNER ENGINEER
C r- Mru"11 AT CROM.71,1. NIT
1535,S0, III)" MEM! MT. !Q00
SAN O.F."RNARDIN-, CA 92408,
SAIV HERNAACJI.3�40 CA 97408
USE OF PERMIT
0W
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SdAQ PA3,,:4V.N(1 A liff,
I Ci 1, R 1,.-, Y @1 -1 -'A Q U J'N T A N 0 R
417.00 8Y
ES1 VIM'4) COWM
P OFONS
CTRUMI ON
PC R MIT 14%, SUMNIARN
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F'$14 (Y
ST0.14C P11,0111014 VC13 - 10"ItSID 101-000-2 4 1 -000
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FRU-3 12.254M-443.2,12 S2,215.6i
Nf"C� VO r
I AW01'UNAM C" 1 1" D C
.4 LESS PRE 4 )AID.FE313S
111111I FEE
U
I B Y
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.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall r
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL AP OVALS
POOLS - SPAS
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
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APP OVALS
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)
N
Desert Sands Unified School District t
Notice: 82-879 Highway 111
Indio, CA 92201
Document Cannot Be Duplicated 619-775-3500
CERTIFICATE OF COMPLIANCE
Date 6/19/96APN # 604-343-018 ,
' r
No. •14611 Jurisdiction La Quinta
Owner Name Century Crowell Communities Permit #'
No. 79210 Street Violet Ct. Log #
City La Quints Zip 92253 Study area 230
Tract # 25363-1 Lot # 37 ` Square Footage 1663 +
Type.of Development Single Family Residence No. of Units 1
Comments
At the present time, the Desert Sands Unified School District does not collect fee on garages/carports,
covered patios/walkways, residential additions under 500 square feet, detached accessory structure`s 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 360-7.464 .,
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. y
Embossed Original- Building Dept:/Applicant Copy - Applicant/Receipt Copy - Accounting