9809-013 (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.
License # Lic. Class Exp. Date
740 M5
p -ate
/� � /.
, � -Signature of Contractor
V —
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).
( ) 1, 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 reaso"�
Date_4 Signatu[e
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
Sec ion 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.
CIGNA. C.4al.I35N
(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
C1ode, I shall forthwith comply with those provisions.
yDate: ri 1/ / 1 Applicant AA
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 ofcompensation, 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. i
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 Quinti, 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 t6comply with all City, and State laws relating to the building
conslructlon and herebyauthorize representatives of this City to enter upon
/Signature
mentlohed property for inspectiopurpooses.
✓ Signature (Owner/Agent) IT_f'f;x, Date
BUILDING PERMIT PERMIT#CONTROL#
/p9
ry,A;t4I.0
DATE VALUATION S271310.40 LOT 42 TRACTJOB
SNE_ I
ADDRESS 79-865 UGA
APN 769-560-043•
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�aC1C�G4,TTC
CA'AL PAC)RC 110VIE rNC�;��111��,
4100 MAC A1t'I`kAJP, BLVD #200
4100 MAC; ARA fUR BLVD #200
NF,W P0R'1" 8BAC H, � CA 97660
NEWPORTBRACH CA. 92660
(()0)622-8400 .0311 15123
1
USE OF PERMIT
Sih`c.. L . FAMILY DW 1ELUNG
8Fb - PLAN 2.AR. ,L031Y;42, FrANUTDOC9 ?° OT WI LIJI)E BLOCK.WALL
OR POOL,
C.YU:,110M CONSTRUCTION 3,306.00 ,'1t
P(XRC.1VPA:r,10 290.00 8
(,MAi.WCAXPOJ. T 5:95,00 S
CON91.2t+iJ(:MON M 101-000-41"00 $$,241,50
14LAN C,- TVMC * ME 101-000-4319-318 $1,005,01
:�L;tiCAiA,'�:tC};�,�?;�� iQ1-Ol1Q-4�1-{231(2 x� glt)3:tl�3
E-LEa'It CA#, "rte ii}.i-iI 't 40[9 X183.91
190- �Q11t�Isy.Sttif
PL+C/�'�i�i,INyG ME��t
q� �1 11pUg00-419-(��t�i1/i�i
GRA13'f&GF2 {_ 2: ^'DOf3-4?3-Qi i1 S2fl.0a
1NFR.MTkUCTURE ME pit 225-00a44,31342 56.00.00
N21 M PItBf:1C" PLACES - t2&S11 3911-OfJti ? S -f 0 3kiZ..3.`�fl
"' , t.� a 1�1.: Ct 1 iS I'f TC'i'1k)N SND �'f.�i N t .�:,1 C
w, j 9?. 3
SEP 2 9 LESS' �',RE-�A� FEES'
$0.00
MLP :�1�'7ii . i.�l ?;,s DugNow
+ 911.92.83
��
RECEIPT;
DATE `
BY 1 -"'-r
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
OX 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 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
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
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
Utilily Notice (Perm)
COMMENTS:
Z0 -d ZtiL9 T8S VTL
a OF Ll QUtNTA
ajNG & SAFEN DEPARTMENT
Of . ' 777-7012
SPECTION REOaUEST LINE
!►' ' 9 777-7163
v. . ACIFIC �OLDYNGS INC
1111,161111 14",
Ow
JTAJ
cont etc; 809-013 P4ACE
pIINSP
it Number JOB IN CONSPICUOUS
PAST ON
Ll APPLICABLE SPADE
ECTOR MUS 79 865I,IGA
JOB ADDRESS j,OT#42, PERMIT DOES
SFD - PLAN 2AR,
NOT INCLUDE BLOCK WALL OIt POOL
uaV.
FINAL GL AS TES
HEATING - AIC
9 HOUSE NUMBERS
J06 COMPLETED
TEMPPOWER
viwlvjivsiNn
UNTIL ALL ABOVE SIGNED
NAS BEEN
U
HT
ABOVE APPROV ITS Do OCCUPY BURL NG O
TURN
003H1 Wd ZZ:£0 NOW 66-ZT-NdC
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 9/17/98
No. 17743 Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc.
No. 79-865 Street Liga
City La Quinta zip 92253
Tract # 24890-3 Lot # 42 Square Footage
Type of Development Single Family Residence
APN # 7697-560-042
Comments
Under grandfather agreement - 3,306 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_ 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 proiect-maytuow be, issued
Fees Paid By CC/Wells Fargo & Co./Manuel�,=edeph66''e
Name on the check •' r h
By Dr. Doris WilsonZ'�
Superintendent
Fee collected /exempted by Juanita Green Payment Received $628.00
1 Check No. 0643036924
Signature
NOTICE: Pursuant of AslAmbly 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 identified I
above will begin to run from 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. 1.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Emb & sed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
0
It