9809-015 (SFD)rr.
LICENSED CONTRACTOR DECLARATION 11,
I hereby affirm under penalty. of perjury that I am licensed under -provisions of
1:7' " Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N w Professionals Code, and my License is in full force and effect.
O :3 License # Lic. Class Exp. Date
LU 13 n Jtiti:
fi
o
Z r- VDate u° Signature of Contractor
U C) OWNER -BUILDER DECLARATION
W a r- 'I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
cr) () I am exempt under Section , B&P.C. for this reason
LO
r nj 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:
Carrier Policy No.
C'.f:ONTA 04041353/4
(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
su ect to the workers' compensation provisions of Section 700 of the Labor
Code, I shat forthwit :comply with P e pro`�Ions
yDate:� Applicant " '_.�-�
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'sEfees.
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 mentioned property for inspectio�n,p77,
es.
LSignature (Owner/Agent) .� 'u�"`C Date
t
PERMIT # CONTROL #
BUILDING PERMIT
9SO-1S f
40 TRACT 2%14)-1 q
DATEVALUATION �� �L .�99 LOTJOB
SITE
ADDRESS 7:0-ciP .�f 1��GA
APN 769-56"40
�► - F9 0
OWNER
CONTRAiCTOR/AD1ESIIG�NAER/YENGINfE7ER
A �) 7 A t� tf�f p y7� f
:�[j.F"i. i�li! i i�.L i.i - ii�dL. x"'.Tos. 1. c.
{,...�1: �1 'Tf.l.e S"f i{.. ii7i�� ii�.)i� i:i� ii'vC
4 i,00 RU'tC r' RTHUR RLVD 6200
4100 MAC AR 1RUR *BLVD #200
i',+t:f cvi'Ott'1'.BEACH CA 9:2660
j,4* P(_wri*,., cF1 CA 92600
(949)622.48400 MAII14 1503
USE OF PERMIT /
14WOLF NWIL-Y >r► Vf L i INO
Sd'1) - .1•fI.At4 4CR, k.t,.i 040, tJti"<! UT DOES .tvCt'E.' 'ClvCla`UIX ALfgCK WALL
Olt P00L.
(110RC°HWA'i O 1 205.00 St.
0Ai{Ai FJr;ARf'?Xe 581100 SF
•�s�7 p �Ra ct•� ,� 0� �tt� 9^�T� t g�,p-�y��
e!n�e,it aid A i �X'C�i<,l.P. OF +6.+.ie VS..iL.b�i±U Z�.'R 9:`1✓l v.,
12 9 C !1 �1�!
' 303,124.10
CONSTRUCTION FEE .101-000-418.000
PLANI CMCti FEE 1,01_0061_439-118
iLTFF. I ANiCAL M 101-�1t10-�1-1300 51! 1.50
l:LECT.RICAL i'liE 101-000-420-000 $198.97
PLUNSING FEE 101-000-419-000 $210150h
STRONO Mi?`1`SON M - RH.SfD 101-000-241-000 SV -z1
`
GIZADINGf.TsE 101-000-423-000 $20.0t3
#NFRASTRUC,TUR11 M 225-00044.1-342 $6.000.00
ARJ' 1N PUBLIC PLACES - RES[C 70.1000-25.5.0,0 $59"i7,81
11: YrAL CONS9.'RUC ION ANLi��PLANn CHECK
y+L ��
MOO
'SEP 2 91999
'SEP
'>!C!":Alt,1►L:i7A9T'i FEW -COU NOW
°J9,.30.59
1%1V OF LA C DINT
7
RECEIPT
DATE
} Y / f
DATE FINALED
INSPECTOR.
d
ti
is J
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
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
Clitltty Notice (Perm)
COMMENTS:
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. 17748
Owner NameCapital Pacific Holdings, Inc.
No. 79-885 Street Liga
City La Quinta
Tract # 24890-3 Lot # 40
Type of Development Single Family Residence
Comments
APN # 769-560-040
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Square Footage 1
Under grandfather agreement - 3,710 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.-thai building-' .,
permits and/or Certificates of Occupancy for this square footage in this proposed projeciay new betissued,°
r 611
Fees Paid By CC/Wells Fargo & Co./Manuel �T21e;hone`,
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by 7uanita Green
a
Signature
Payment Received $628.00
Check No. 0643036924
NOTICE: Pursuant of Asse%yfbly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify ycu that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run fro he 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