9905-265 (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 fulue and effeul.
License # Lic. Class Exp. Date
JJ0745a 13 AM130/19'.
bate ` P Signature of Contractor J=
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 sectior�n 4e6not be completed if the permit valuation i"for91101M0 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 Jorthwith comply with those provisions.
(Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $160,000, 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 i
whose request and for whose benefit work is performed under or pursuant o
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 above-mentioned property for inspection purposes.
Signature (Owner/Agent) ` �' ate
BUILDING PERMIT PERMITN
DATE VALUATION LOTAS 265 TRACT
IT
(-r 6 d •911 .�
JOB SITE
APN
ADDRESS
74-24 T3V(_ - i T
OWNER ' CONTRACTOR/DESIGNER/ENGINEER
CAPITAL PACIFIC HOMES INC CAPITAL PACIFIC HOMES [NC.
4100 NIAC AR1,14UR BLVD #200 4100 MAC ARTHUR BLVD X3200
NEWPC)RT BEACH CA 92660 NEWPORT BEACH CA 92660
(949)622-8400 CBL-# 1503
USE OF PERMIT '
i-
4 U
r
S c1...Mc r `Lr '
Std -.PLAN 3C LOT13 - PERMIT DOES NOT INCLUDE BLOCK 4W.M.LS
OR POOL.
CUSTOM CON'STRU&fION 3,400.00 9F
PORCRIP —110 268.00 W ....
OA9tAiTJCARPORT 53.9.00 SF
ESTIMAXE12 COST OF CONSTRUC, f1ON
279,968.811
EERNHT EEE SUMMARY
CONSTRUC'PiONFEE 101-000-413-000 $1,269.50
PLAN CHECK FEE 101-000-439-318 $1,0'-.4.51
MEQ ANICAL FM 101-000-421-000 $98.30
ELECTRICAL FEE 101-000-420-000 $188.28
P1,UNIi111_I0F'E)i _ -001=000-419--000.
STRONG MOTION FEE - SED ' 181-ti00-241.000 S28.00
GRADING FELE 101-600-423-000 a0,uo
i1`TRAS�'1t11C�IVR11 FFY. x`625-000-443-342 16,000.00
ART 1N PUBLIC`. PLACES - MIC 701-000-255-000 $4.19.92
' 'AL CONST1 M -MON ,AND PLAIN CHF...CK
$9,259.21
L.ESS PRE -PAID FEES ES
$0.01)
JUN..® 81999
TO"D'j's.L PER1111T FE.& i1T71 ZVO�
59,259.21
6V 0 b F.d^\Q-1N'Ib`T,
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
i7;
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
- U -
Exhaust Fans '
O.K to Wrap
G(/
F.A.U.
Framing
Insulation
at%
Compressor
Vents
C4 49
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- C<7
Drywall - Int. Lath
Final
s l
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I
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
- ev
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 41 Fi
Utility Notice (Perm) C
COMMENTS: