9905-277 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty ofperjury 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
74.0745 I3 Ofll30119!
die i`•� r ��Signature of Contractor ' f `?�-- t
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:
O 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
Se,C112i n 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.
This section n eii not be completed if the permit valuation is fol X100.00 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. p
Date: 0' e -Applicant eA / /') _ -
u:
VWarning: 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 sucli,
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 inspection purposes.
/ J n
signature (Owner/Agent) 04;;6. _ t% A � 4 Date , M �
BUILDING PERMIT PERMIT#
DATE. r VALUATION LOT 99#1&277 TRACT
$2-54,511.5033 .2_4I390-.1
JOB SITE
APN
ADDRESS
79-795 .SANMA.
769-.570--027
OWNER CONTRACTOR/DESIGNER/ENGINEER
1 ,
C.A,PITAL PACIFIC HOWS INC CAPITAL PACIFIC HOMES :1 ,,,
4100 MAC ARTHUR 81..,VD ?1-200 4100 MAC ARTHUR BLVD .000
NEWPORT BEACH CA 92660 NEWPORT BEACH CA 926560
(949}627-13,100 CBLli 1503
USE OF PERMIT
rinihvl `1'iw a Y a, 'R/?art
AFD -PLAN 1C Lor33 •- PERMIT bOEES NOT 1NCLL0_ E 9LCCrs WALLS 011.
POOL; CifiEt,X PbR1I0N 7E FU :KMUC.�:D 7.5% FOR NIM.17PLE
.CLTST01V1 CGN'S'['.RUC•1 ION 3,069.008F
PORCI-TIPA.TIO 328.00 SF
QAI'.A0FJCA1iI?G?RT 565.00 SF
ESTIMATED CM OF CONSTRUI •PION
254,»51 3.50
PERMIT FEE SI.T 111 Y
C ONS'1'RUC 11710N FEE, 10.1 -CM -418-000 $1,152.00
PLAIN CHECK M 101-000.435-318 $N8.99
MECRIWCAL FEE 101-000-421-000 S98.50
ELF.(_' R:fCA1., �FP..F.. 101-0010-420-000 S 170.2*2
PL[.WB(NCr tirEE 101 -000 -419 -MO $168.50
S MONG.MOTION FEE - RESID 161-000-241-000 V25.45
GRADING FCF 101-000-42341110 520,00
i�th.ltASTR fC;TLIKE FEE3 21'15-000-443-342 $5,628.35
A.RT IN PUBLIC KA -CIES -1? s.Sfi: 7014000-255-000 53g3G,24
4 .
r.
AL CONSTRUCTION AND PLAN CHECK
Tlo
,LESS PRE-PAID1~EES
JUN 0 81999
TOTAL .PERAUT FEES L3I3'i+ NOW
57,934,29
OF LA QUI T.
]1TY
tA7.
RECEIPT.
DATE
BY. ! 0 1 7DATE
FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
et
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Steel
2_
Return Air
Combustion Air
Roof Deck
Exhaust Fans
O.K to WrapF.A.U.
Framing
(. - Q �r
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final GtJ
Final o` cu
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
ewe Connection
—
Encapsulation
Gag'Piping
Gas Test
Appliances
Final
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
Final
Utility Notice (Perm) _ C-</ Ti��
COMMENTS: