9809-014 (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
740745 .5.1 9i30J99
Vb/�
`
ate � � �"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.
(k� 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:
Gamer . Policy No.
CIGNA C404435-31
(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 Sectio 3700 of the Labor
C�de, I hall fo hwith comply with those provisionO .�
ate: 70' Applicant-ort
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. 0,
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 1
.& 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 inssp�e_ctio purposes. C`� G .fid
/Signature (Owner/Agent) � ►-`E Date` /w
PERMIT # CONTROL #
BUILDING PERMIT
4309_„4
DATE VALUATION S27 ��1 . �'i LOT 41 TRACT
J
3 �/jig
ADDRESS G 79-87 1XIA JOB SIfE
APN 769-560-4141
OWNER
CONTRACTOR / DESIGNER / ENGINEER
f CILDT1;'GS, INC.
CAPITAL RAMIC HOMES INC
4100 ivlAC BLVE) #200
4100;KLAC tLfs.`i`C UR F3i..VL,4200
NEWePtJkt":i'BEACH CA !26&;
NtVi.P0.tl-`8EACH CA. 92660
(940)627.8400 C€110 1503
USE OF PERMIT
S9'MGL}I A&11t'V ;OWELL1. G
UM-?:f.Fu� .tut LO-41,i°,E- fitD UNOTi UTs,%iLC^f WAY
Cu"T1101M l.'C'rivS7i'. tuC 3IC?.%, 3.400:60 S.F
;SO.�G.H/lixtio 268.00 .IF
t rid Id sCi yC Al2:tjCa 't 389.00 3
r l l ' f'1 i Ci F CO�i :, IC31
77"3963.30
PERMIT r'U, f',,SUMMARY
CONSTRUCTION ME 101-000-418-()00 $1,269,St)
PITIAM C"TCJ : M.
lU.'l�CF.1AINICAL FHE $98.30
O tys."'I iCAL F0 101-000 420-000 $188.°
N U41413 +f( k.� 101-000-419-000 si£40.5e?
010 0 -24.? -000$28,00
JTJ)3OIV_JT,14)N FEF F R SD) 101-000-24J-000
T "i6�0UV4GRADiNJ'.1011-(1V
-
Ci+1F'RASTRUC;TURC Fhb 225-000 443-342 6,t lf9.fHi
Al2.'[ IN PUBIAC ft.AC) p - MSS 1-000-255�OW $"9.92
SU43=1OTAL. C(YN.51- UG ft_0 `i .AND PLAN CHECK
LESS ;SRL,-PAID EES
WOO
PAIS
t..
iTOTAL PEI7MI €.F.9 DUE NOW
t4
$9,V1W.21
SEP 2 91998
ayof-
R BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
---0 zle—
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. LathEA
2
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
ZV—
Heater Final
Water Piping
_
Plumbing Final
.Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Server 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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
t
Final
Wility Notice (Perm)
d
.
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 9/17/98
No. 17747
CERTIFICATE OF COMPLIANCE
APN # 769-560-041
Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc.
No. 79-875 Street Liga
City La Quinta zip 92253
Permit #
Log #
Study Area
Tract # 24890-3 Lot # 41 Square Footage I
Type of Development Single Family Residence
Comments
Under grandfather agreement - 3,400 sq. ft. (The Citrus Course)
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 project.inay now be issued
Fees Paid By CC/Wells Fargo & Co./Manuel
,Telephope ;
r.• n �
Name on the check ,
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $628.00
Check No. 0643036924
Signature
INOTICE: Pursuant of Ambly 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
above will begin to run fr15m the dale 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.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
r
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