SFD (9905-274)50965 Mandarina
9905-274
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section. 7060) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.., t
License' # Lic. Class Exp. Date
LAIlate"
Signature of Contractor
OWNER -BUILDER DECLARATION
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).
( ) I,.as owner of the property, am exclusively •,contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C.:for this reason
Date Signature of Owner
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 -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.
. )0I 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:
Carrier Policy No.
(This sectiorT nNe6not be completed if the permit valuation is`fo r 11,101W0 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall rtl w th comply with those. pr vitsions„f%
/D te: 9` `a LjApplicant—
/W
pplicant fir(' `
/Warning: Failure to secure Workers' Compensation coverage is unlawful and
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
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 :1,
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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Mature (Owner/Agent) #`ha•/ C/!tDate
BUILDING PERMIT PERMIT#
DATE/ C{ VALUATION LOT "0-9-2,74 TRACT
q9
..
_S303.123.10 '75 :24€90-1
JOB SITE
APN
ADDRESS
50-965 M ANDARiNA.
769-570-0.19
OWNER CONTRACTOR/DESIGNER/ENGINEER
CA;PrrAL PACIFIC HOMES INC CAPffAL PACIFIC HOMES INC
4100 MAC ARTHUR BLVD *'200 4.100 MAC ART 4UR F3LVD 0200
NEWPORT BEACH CA 92660 NEWPORT SE-A.CH CA 92660
(949)622-11400 C131A 1503
USE OF PERMIT
1 J.t `d •4 ♦ lL J Yr.i✓. 1,LLY
S.FD - PLAN 4B LOT25 - PERMIT,T30ES NOT. INCLUDE BLOCK WALLS OR
P;J0 ..PL hI4 CWCK PORTION OF Fart:- REDUCED 75% FOR POU TIPLE
CUSTOM CONSTit SL'11ON 3.710.00 SF
PORCIWA.TIO 205,00 Sr
GARAGE/CARPORT 53.1.00 SF
I1rurm1s.1) Can ol? C1J: 1SI";mu rioii
301,12-3.14P
P.IEItMIT FEE SUMMARY
CONSTRUCr1ON1,5E 101-000-<118-000
YLAN CklEC%. FEE 101.000-439-318 $274.."10
tviECHANICAL FEE 101-009-421-000 S1.11,50
43"EC'1 uC11L:FEa3 101-000-120-000 '$198,97
1'T,UXIBING h'EE 101-000-40-000 `321.0.50
S itCi:t G rviOTiON FEta - R SID,• 101-000-241-000 $30;31
GRAUt`NO FEE 101-000-423-000 520.00
iNFI'LM'. RUC'1 UR,t+ IFES" 225-000-443-342 $6>000•00
A1 T,IN:PUB1AC.PLACES- R.ESID 701-b00-255-000 $507.81.
ALCO9YIMU11ONJD HEC
A8C-PAID
$8,707.09,
-
LESLI 1E»l
$0.=9
JUN .0 8 1999
TOTAL 1PERr'NI FEES .DUE MONY
$8,707.09
9 77 gg yy ,
0 i I iT
-ATY .LA .U.
RECEIPT
DATE t
IBY V
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
I`••
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
0. K. to Wrap
F.A.U.
—C
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
steel
POOLS -SPAS
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
Z.
Appliances
Final
Final -
Utility Notice (Gas) Cd
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service - Cr/
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final -)
Utility Notice (Perm)
COMMENTS: