9809-016 (SFD)LICENSED CONTRACTOR DECLARA=IO�d
I hereby affirm under penalty of perjury that I am licensed uncler pry vistaris, of -
Chapter 9 (commencing with Section 7000) of Division 3 of &h Business-arfd
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7.10745 bi k -10.194
ate • Signature of Contractor ew
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:
CarrierCIGNA
t pp � Policy No. 0404
C
(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 provision /j
Date: a/r ; Applicant � , W- s
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 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
Zthe above-mentioned property for inspection purposes.
l
ignature (Owner/Agent) �J� � �� � • +>� Date � `� �%
' PERMIT# CONTROL#
- BUILDING PERMIT���►
DATE // VALUATION+d +yt�a70 LOT' 39 TRACT 2
.b
JOB SI tr i r•��tS
ADDRESS i4.4:�:J !/�t A
APN q
I _039
OWNER
.ONTRACTOR/DESIGNER/ENGINEER
Ci'1.ALp�iC1FIC iJLIIE\S, INC..
'A i3AL PACAFIC LOVES r NC
4100 MAC AR'iTRM BLVD #20-0
4.100 .WkC A;i::%, UR Kvb #20th
NEWKA;(r BEACH CA 92,660
N•I?WPt; Wl BEAD H CA. 92660
j
(94.9)622-8400 CB11# 1503
USE OF PERMIT
SINGLE FA.i� ItY DWELI INCY
Sly - PLAN2C, LC)'I 19,.F'.wvfr'i'T)OF,S Nar ji%,a'LiLc ar_ocK wALL
OR PWL.1'.LAIN CHECK F .44kL�i�GEt3 �Y? "t5°io FOF€11.fi fir�'i�:
13SL =NCE Or- SAME PLA14 TYPE.
C'L3S'1`JM CON= UCi'TIQN 3d34M.00 SF
PORCKIPr r10 290.00 SF
0JAR 0EtC.A` 1..-40 tX 53S.00 Sp'
J. aYNNI.P. T.ED =", OF CONni'.@.'RUT,4. 11'10
2 114�Oil .40
OONS'i'E2UC'i'i:ON FEE 101a)0-418-000 3,?fF.4.50
P1,AN C�.Osy` . r�T !01 -MO -439-318 S25f.26
XTEC9iAN MIR 1.01-00 )-4 1-OOGi $.105.00
lel f`"IRf.S;AL F119 101-Of70-4.20.000
PlILMI3INcFEE 1.01-W)419-000 3f.t3C�,30
S'TROT 40 ' 170V F.R REEK) 101-000-241-0M, Sau ?, 19
i.A 9 7 �t�Ii-00U�4ni3-OiIU MAO
1Xf-'RA.TfAilc`° (MJ F.F.E 2155.OW-443-342 5+(i3Of1U.0Ct
AR.'i' INPUBLIC PLACW - RESIQ 71I.040-:35-000 $4.N. 10
A � il4i "I1tLTi."TIC� A�iV1� PI.,;�:Al j61E, ;
Si :4.39.06
�` L.F34,�' PRE -PAID FEES
MOO
SEP 2 91998 TOTAL VERT f FERN Du.�NOW
Sa4,439.06
0f= LAQU 1
.J1 e i tlT1A
RECEIPT
DATE
DATE FINALED
INSPECTOR
y
s
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION -
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts .
Forms & Footings
Ducts'
Slab Grade
Returh•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:
-
r
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures r
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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 APN # 769-560-039
No. 17749 Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc. Permit #
No. 79-895 Street Liga Log #
City La Quinta
Tract # 24890-3 Lot # 39
Type of Development Single Family Residence
Comments
`Zip 92253 Study Area
Square Footage 1
Under grandfather agreement - 3,306 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` d that building_
permits and/or Certificates of Occupancy for this square footage in this proposed project may now..be issued
Fees Paid By CC/Wells Fargo.& Co./Manuel
`Telephc�ne
Name on the check "< -
�, Z *' rc
By Dr. Doris Wilson �' `f "
Superintendent
Fee collected /exempted by
Signature
Juanita Green Payment Received $628.00
Check No. 0643036924
INOTICE: Pursuant of Assem19y 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 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.
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,