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9905-268 (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 740745 .. $ 4130119!, V/ate Signature of Contractor 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 bj Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 0,0 1 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. 1. (This section# ON � not be completed if the permit valuation is fo $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 p�ovisio • s. —D te:_ 6 , �' � Applicant M r' I `� '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 atI 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 s & 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. �Ignature (Owner/Agent) �� +^�.tie:�.�! ��"/. "7.�:• Date BUILDING PERMIT PERMIT# DATE VALUATION LOT 9905-•;568 TRACT 15 74890-3 JOB SITE. APN ADDRESS 79-880 TANGELO ?ETRE CT 769-560-015 OWNER CONTRACTOR / DESIGNER / ENGINEER CAPITAL PACIFIC HOMES INC CAPITAL PAC'1r,'IC.- HOMES INC 4100 MAS, AfZT14UR. E.1„ VD I#200 4160 MAC A.I 114UR BLVD #200 NEWPORTEEACH CA 92660 NmPORC.BE.f1CH CA 92666 (449)622-8400 CEL# 1503 USE OF PERMIT n u cu• a .s.,u x. 9F D - P :AN IC LOT'ia , -;PF. Mi'T DOES NOT N(MMIDE S1rC C3` WMLLS) OR POOL CUSTOM COr'3't'RUCTION 3;06.9.00 KF PORCHIPATIO 328,00 SF GARAGE CARPORT .565.00 SF W9.<aWED CClY1 OF C014SX' UC:TTON 54,511 50 PERMff EEE SUMMARY CCJNSI'RWrtONFEE 101-W0-418-000 $1,132.00 PLAN CHECK FEE 101.0004439-3.1.8 $955.91 MECHAM AL F M 101-000421-000 $98,50 ELEM'RICA,L M.; 101.-000-4.20-M $176.:22 -- PL LNG T- [I17 ={}Oti 41 00 --- -$1,-68a0 - — 31RONG MOTION - .REsm 101.000-241-000 $25.45 GRADING FEE % 101-000-423-000 S20,00 iN IR,F1&MUC CURE ��23-000443-342 $5,628.15 ART IN PU13LIC PLACES - l2lr;aW 7091 -000 -?55-000 $386.23 iIIJ1010TAL C©NS"i1tCIC11ON AND PLAN CHECK $8,641,211 PA .1.RSS i�ltl�-PA.I13l.L1?S $0.00 JUN 081999 TOTAL PERMIT >h EFS DUE NOW s .641.0 RECEIPT DATE BY, DATE FINALED INSPECTOR f 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 — G(f Compressor Insulation U -f Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final — - cd Final � - C/ 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 , W Appliances Final Final Gd Utility Notice (Gas) —C -C, - 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) COMMENTS: