9905-275 (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
1=10745 B 0 i30/.
Vate %" 9-. 9F Signature of Contractor -4a
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:
Carrier Policy No.
(This section n snot be completed if the permit valuation iC4041,3334
for�$t1�0 X00 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.
Date' %a ^ 5�� `� Applicant
Warning: Failure 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 forin Section 3766
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 onhis
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 ik
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.
Sigi ature (Owner/Agent)`".Pu �--�-� 11r° J! :.Date V
r -
BUILDING PERMIT PERMIT#
DATE VALUATION I LOT "03-275 TRACT
g $2.54,511. +i1 26 241890-1
JOB SITE
APN
ADDRESS -
79 -tea ��1Nl�•[�
7b9- 5570-020
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CAPUAL RAC MIC HOMES INC
CAM x AL PACIFIC: HOMES INC
=tY 00'MAC ARTHL IR. BTATD i#200
4100 MAC ARTHUR BLVD 9200
NEWPOR.T'BE VC'H CA ?daub
` N1sti POWr BEACH CA 92.650
(949)622-8400 CB,L9 1503
USE OF PERMIT
SFU - PLAN 1.13 LOT26 - PERWT i30F:5 NOT INCLUDE. ALOCK )VALLS OR
POOL,.. PLAN CHFCK PORTION OF FFE :RF..nUMD 75% FOR WIMPLE _
fSS1.FAAICF OF 3A&IF PL AN T1W,
CUS'r M CONSTRUCTION 3,069.001 qF
PaRCJVPAT.10 328.06 SF
(JAR.tAGIEVCARPORT
MST OF COMST1t @!C°i'10N
2U,511_54)
PERAR T EEE SiTlAiMARY
CON STRUC.^.TION tF„ E 101-000-41"0 Sl, iz d.t�4
PLAN CHECK FEE +01-000-43,9-318 SZ48,99
NIECKANWAL FRE' 104-000-421-000 $95.50
1. LEC9 R:ICAC, Fr -P, 101 000-420-1300 $.176.2
itiLtlt4ft3tt3t, F't E 101-000-419-M $I0;50
.Trf,ONO r%1(: rICN.FEEE - RESID 1014)00-2.41-000 WAS
`
-GitA.DINO F F 101-000•-423-000 5411.�►f3
WR.AS R.UC'r11t11rFEE225-000-443-.342 55,62&35
-
A11`r 1N PU LIC: PL AC,`F'S - T2:SSIC 701.000-255-000 $3$6.213
S'
' SU AL CONnKL ICTION AND PLAN C1.1ECK
r.;
P,9134.'!1^�.�'I
11P
LESS �':1t1a�1' UD FEES®7'A
.P1ERAUT €EIS DUE NOW
� 199 '
$7,934.29
juts ®. �
RECEIPT A
I
By I(�
DATE FINALED
INSPECTOR
/1
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
0.K to Wrap
F.A.U.
-
Framing
Compressor
Insulation.
2- 22 - '�q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Z
Drywall - Int. Lath
Final
Vp• /0 --
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
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 LinesHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
SpWr Lateral
Pool Cover
er Connection
Encapsulation
Piping
Gas Test
..
Appliances
Final
Final jJ_ ev
Utility Notice (Gas) -e-
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 - U• Gts
Utility Notice (Perm)
COMMENTS: