SATT (9808-009)50970 Mango
9808-009
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that'l 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.
LicenserA*J43 Lam. Class Exp. DA60/99
Date '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.
( .) 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:
Carrier fINDUS1'RIAL BID= Policy No. CN90.10`:Z4
(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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of th Labor
Code, I shall forthwith comply with those provision
Date: b Applicant rn
Warning: Pallure 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
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 pu{rrposes..%
Si nature (Owner/A ent) i' ^ X / 1. Date; ///
>jz„ , UILDING PE I IT PERM IT:#19aS-13tsv CONTROL#
2 ;,F .t.. _ 40 24NO-2
DATE + VALUATION. LOT TRACT I
470
79
JOB SITE •` • ` .v
APN Y- y
ADDRESS
l
OWNER y
CAPITAL Pit: lFIC H01,113ff1C..S ,i C
CONTRACTOR/DESIGNER/ENGINEER
C AP1`f. 1t. PA.Cl.Fs1C::-IOMES ):SIC
4100 MAC A i.:!'.l:tUR BLVD ft200
4►00 MAC ARTHUR BLVD //.200 '
NEWPOW BE1kC-1-{ CA 92660
NEW'rT(3fi`1' 13LAC1-! CA 926,60
f 714)622-8400
USE OF PERMIT
SINGLE FAMILY AT1 ACJED
A M. AwT R G:Y*41:1f1 iT'!Y: sr':• raY'x. 'Ar K.
YI"iT ,!Yr__YGS' a ArTO
01kPOOL. F1 AN CH1-.CK F tif".'I.t .1. UC.E; 8Y 75% F R Nl10L1V'1LF11SS(tANCf
Or SANE PLAN TYPE.
CUSTaN11 C NST WOCTfoN 2,6]2,00 SF
Pt91WRYPATTO 200.00 : F
0MUNOWCARPCU.Ft'f' 647,I10 SIS'
L:»9' 1 4A%,E,,D .RY I ii O \C..+ .g1V.'i5i. RUCTION
231- 7>16.00
PERMIT . +` E' STIMtMARI'
CtN4Sr1WCT).0NFU 101-00,4'At1-4)00 sli,o6.fl0
MAN CHEY,,39 j'EF, JOJ-M,04:39-11 8 SWIM
h t;,r:;ii3, MC ,i...P"M ]01,000 92,i»4t3R $92.60
1:C.LG"" ICAL FEE 10.1-{)00-420-000 $161.116
P:LUNIBING FEE 101-000-419-000 $167.2.5
1'rE r ? O NKY!.'ln r1 _ RESID 1(11-0110-241-4)00 t 1.n8
GIZADINC; FEV 101-000-423.000 $'HO.00
INFRASTRUCTURE PEE 225-0017-443-342 3pW4.51
PRECISE PLAN 10J. -M-441.-344 $25.00
AR7 iN Pl BL'!C PLA_< a -RMSM 701-M-255-000 $297,0
tr13-TC71'11,L C'Ca1+f 1 2.LTC1' ON AND FI:E1N ChWCK,
$6,919,62
LESS 1'R -iA1D EES
$0.00
TOTAL P:& fNl1T 1k'EES OVE NOW
$6.919.62
r\
RECEIPT
DATE
DATE (
BY ( f
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
��_
PSG
G (
Underground Ducts
Ducts
Slab Grade�
Steel
/���
ReturnAir
Combustion Air
Roof Deck—
OX to Wrap
Framing
/.0
/ . _�G(
��`
Exhaust Fans
F.A.U.
Compressor
Insulation
2=z, _
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
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
Water Piping
_
W09
Heater Final
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
57 �OI
Final
COMMENTS:
Final
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
_
Utility Notice (Perm) 5�!
Building
Address Ja'M 970
Mailing
Address 12526
City Sluff Dr- Suite
Zip ITel.
Contractor
SM
Address
Zip I Tel.
State Lie.I City
& Classif. Lie. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lie. #
4
6u
P.O. BOX 1504 No. v 7 80 T
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
t ,LICENSED CONTRACTOR'S DECLARATION
I hereb a fi m ha I m licens d under provisions of Chapter 9 (commencing with Section
7000) of y i sggon }o t stn sand Professions Code, and my license is in full force and
effect. D ] f t f ""`^., f s ..- -
I I
OWNER-BUILDER DECLARATION
I hereb affirmr that am exempt from the Contractor's License Law for the following
reason: (Se 703'.I.S,B iness and Professions Code: Any city or county which requires a
pefrilit to con,¢truct,talter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such peril to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he Is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or Improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT., If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. y
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date -
Mailing Address
City, State, Zip
BUILDING:. TYPE CONST. OCC. GRP.
A.P. Number Citrus Course
Legal Description Tftct 24890-2 Plan 38
Project Description Lot 4
Sq. Ft. 2747 No. No. Dw. .
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $200.494
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal. Rnn 22
Const. 6612 on
Mech.
Electrical
Plumbing 2
a 67
S.M.I.
Grading
Driveway Enc.
Infrastructure
r t
TOTAL ( j „ N J i `'-
REMARKS
"401 iK,o
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSr PEC gORR
Issued by: Date Permit
Validated by:
Validation:
CGNSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SQ. FT.
POR. SO. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. FT.
WALL SO. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
REMARKS:
GAS PIPING
PERMIT FEE
PERMIT FEE I
I PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR'
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL