9809-012 (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 and
Professionals Code, and my License is in full force and effect. A
License # Lic. Class Exp. Date
a /74074; B s i 9130/99
teate A?"- `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.
(�Y!) I have and will maintain workers' compensation insurance, as required by
Seotion 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.
C T"L A C/l PI35 �
(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 the Labor
Code, I shall forthwith comply with those provisions.
ate: f 9.a Applicant_ 01A g ;7. 14
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
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 1'80 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'purpo/ses.
t,4 ture (Owner/Agent) � �/ �� Date
BUILDING PERMIT PERMITCONT RO`#
ssl�
DATE VALUATION .4,511.-;0 LOT 43 TRACT 2,8410
qAq Gn
JOB SIVE
ADDRESS !gA-i;S.�Y+H a.liAtl .
APN %C1S�-JVIi^d
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CAPITAL PACIFIC I-101M,'INGS, D.C.
CAPITAL PACIFIC H4 MES' !'C
4100 MAC Aid rHUR 13L V U #`00
4100 alIAC ARTHUR HUR BLVD #2.00
'NEWPO'WrBEACH CA 92660
N F W P(;3RTBEACH CA 926611
(949)622-8400 C13IN 1503
1
USE OF PERMIT
O
TNGLER FAMILY DWELLNO
FO IAIt,, LOW 43.R"T DOES 1144'1' iNK'l;aiDE:RLOCk WALL
-PLAN'
CUSTOM CONS'1RUCII ON 3,069,00 S1~
PoJ:C,`H PAX10 328.00 8F
t3r4"kA565.00 SI:
ES TMI.AtE, D Cr`.aS T OF CONI STV'XIC'X ION ' .
L54,511..50
PE Ru.n" F%.'1�✓ SW ` iWAR
C+ONSTRtICTION FES 101 -WO -1118-000
Pr AT?C IrKiC-K 1 ME 101-0130.439-318 5955-34
101^QW_ -421.000 $98.50
1:WITRZ4li1', FEE 101.00420•007 $176.22
PLV1Ll.Rfl4G FEIC 101-000-419-000 16F5.St)
;J l ONO MOTION FE; - RES14i 101 -000 -2 -ii -000 $2S.45
CrF. WIN. 'a rL118 101-€)-123-000 �2fl,4G
1WR&%,fRUC"1'"aE FJFIG 225-000-443-342,
AR'T 1W PLJBL,1C Pl<AOE$ -1Z SID 7014W,255,,000 #5.
S ..$` C.C,31�1' 4'I'1t. t!N AT�L� E�:�1�3� (��"i�:C�';
t
�' _ .r
a <t LESS P&S-PAIT)FEES
SEP
40,00
Qi
Y3 p oU�i��
3AV
J
k
RECEIPT g4
DATE
BY
DATE FINALED
INSPECTOR
Ir
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
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
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 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
c �
Final
Utility Notice (Perm)
'I
Notice:
Document Cannot Be Duplicated
Date 9/17/98
No. 17741
t
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameCapital Pacific Holdings, Inc.
No. 79-855 Street Liga
APN # 769-560-043
Jurisdiction La Quinta
city La Quinta zip 92253
Tract # 24890-3 Lot # 43 Square Footage
Type of Development Single Family Residence
Comments
Under grandfather agreement - 3,069 sq. ft. (The Citrus Course)
Permit #
Log #
Study Area
1
No. of Units 1
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:
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Mitigation Agreement in the amount of
628.00 X 1 or $ 628.00 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed pr,oje t rnay,;now be issued.
7-
oAw
Fees Paid By CC/Wells Fargo & Co./Manuel :Frcle hone
Name on the check
1 -
B Dr. Doris Wilson"• _
By Superintendent ' l �`P
Fee collected /exempted by Juanita Green
Signature
Payment Received $628.00
Check No. 0643036924
INOTICE: Pursuant of Affiembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identifiedabove will begin to run fYom the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
L Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
e
' 79-855 LICA
JOB ADDRESS
SPD - PLAN JAR, LOT#43, PERMIT DOES
NOT INCLUDE BLOCK WALL OR POOL
TYPE OF INSPECTION
DATE INSP.
FOUNDATION &SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE -G NITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
,lO1STS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH GAS & GAS TE
HEATI NG & VENT - AIC
FIREPI.AI.0
ROOF
BOND BEAM
O.K. TO WRAP
GROUT O 4' ❑ 1 '
FRAMING
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN
DRYWALL INTERIOR -
EXTERIOR LATH r�
POOL PRE pLASTER
POOL PENCE & GATE .
SEWER SEPTIC TANK `
PLUMBI
AS TEST
3 -AIC
NUME*1
FINALS
7-7--
TEMP POWEfl
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING
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