9606-085 (SFD)LICENSED CONTRACTOR DECLARATION
`'that 'I licensed under
%'- '��' BUILDING PERMIT
PERMITi CONTROL#
I hereby affirm under penalty of perjury am provisions of
aif ►+l�,ie 3 5 9
Chapter 9 (commencing with Section •7006) of Division 3 of the Business and
DATE V LUATION LOT
TRACT.
Professionals Code, and my License is'in full force and effect ; r'.
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License # Lic. Class Exp. Date
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JOB SITE
ADDRESS
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APN
604-343-617
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Date, Signature of Contractor
OWNER
CONTRACTOR /DESIGNER /ENGINEER
1 r V:
OWNER -BUILDER DECLARATION
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1 hereby affirm under penalty of perjury that l'am'm exempt from the Contractor's
License Law for the following reason:,
.
tiE P3 B} }t.ltit>fdj�fiVi i A 92408
SANe$Iy'P�,NAftOWC) CA 92,408
( ) 1, as owner of the property, or my employees with.wages as their, sole
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compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
sale (Sec. 7044, Business & Professionals Code). , .":' s
I, as owner of the prolEierty,.am 6xciu_s6ely contractin with licensed
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contractors to construct the' project -(See.".7044, ;Business &-,Professionals
hilRls. }.,$' ' lh�l8i,l la�i�f.t-.l.ttsEia
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Code). :, ' :; , ,�
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13IATE-IRSIDE. C,A.tis
O I am exempt,under Section B&P.C. for. this,reason • • ` /
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Date . s Signature . of Owner + ,Y
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WORKER'S COMPENSATION DECLARATION, ••,'"
I hereby affirm under penalty of perjury one of the followirig declarations: '
I't#,Ac.i',ii7.tff�tk:['.t�4'tf�id f'{t�6,t)Ct�ft"
• O I have and, will maintain a certificate of consent to self -insure for workers' �
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• compensation; as. provided for by Section 3700 of. the Labor" Code, for the
performance of the work for which this permit is issued.`, - tfAT�AOfg,:A3.tiy}d.t• 413 Ettt 8I' ,
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 I
permit.is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ° Policy No. N P w
gift ytil, iii: f Il�`��i'gx��i; :�EY,9051VI OWIACUNNi�Yi:J(�.�ztA , rl.94i.56
(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 �t`44-f,a i R,LIC T ON 1',1 is
workers' compensation laws of California, anclAree that if I•should becoml� &tLallii�Nt�)[11, 1" }� . • "1.f11 -ii iii -36i -ii Vii! ttiy
subject to)kie workers' compensation provisions of Section 3700-6f the Labor
131 F, f.�� cAL Fui, 7ung-I,l(w.42Cf-000 $ jf:Y .9Q
Code, IdsMall f 7rthwith comply with those ps:
rovision'„r-- ,
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Date., AP,Plicant
aTONO) i� u� l� 1`� {"3'.is � 8�.i�39.P.3 ��r �•i,al..�-fe>�r' �v rs}
Warning: Failure to secure Workers' Compensation -coverage Is unlawful and a,.ttrlU:if�� #+t:ls �U:i-t1QU-4;3-i}0�Zt).iiU i
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages'as provided for in.Section 3706
t Nig R / :y'i'f2C.tG").11�E:lh`C31,-'
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 onThis
application.
1: Each person upon whose behalf this application is made &"eachperson at
t whose request and for whose benefit work is performed under or pursuant to ' ' "' n •`4., L i f # Iw ` (J ry ," V - 6e..�4N CHUCK ,- 1,
any permit issued as a result of this applicaton agrees to, & Shall,,indemnify `' �' C `p ) '
& hold harmless the City of La Quinta, its officers, agents and employees.rrr�, .
r i ESS 1'Idi
2. Any permit issued as a result of this application becomes null and.vold if
work is not commenced within -180 days from date of issuance of 'such )•. �Sf4 Ap �• ,
permit, or cessation.of work for 180 days will subject permit to cancellation. I TOTAL � 9""� 9' ( CS DUE NOW
p Y_ ; P U N 2 °<< tg9G
I certify that I have read this application°and s at i that the above information is r,
correct. I agree to comply with a11. City, and,State laws relating -to the building r '
construction, and hereby autho ze representatives-& this City to enter"upon
the above-mentioned property for inspection purposesF'
j ,.•" .,� RECEIPT DATE BY • DATE FINALED INSPECTOR
Si nature' Owner/A ens �J �' Date�j�f
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION I
DATE
I 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 Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS •
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping AW
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPAO,VALS
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 t APN #' 604-343-017
14610
• No. • - ,Jurisdiction La Qulrrta
Owner Name Century Crowell Communities Permit # N
No. 79220 Street Violet Ct. Log #
City La Quinta zip 92253 Study Area 230
Tract # 25363-1 Lot #' 36 Square Footage 1461
Type of Development Single Family Residence No. of Units 1
x -
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 --s 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
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. Ballesteros
Superintendent
Fee collected /exempted by Pauline Pearson,, Payment Received , $2,688.24 _
Check No. 28118
Signature'r. -Q,A A V c g T1 Axl f-vTu
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