9809-019 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under, provisions of
CAapter 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
x4€,74 13 !3 f✓9
dateSi nature of Contractor f �
til . � � g
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:
Cartier Policy No.
CIGNA C40-11.35?4
(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 Secti n 3700 of the Labor
�6de, l II o 'th comply with hose pyovisio
I Date: . Applicant —& //, �e
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damagesasprovided for -in Section 3706
of the Labor Code, interest and attorney's fees. „,
IMPORTANT Application is hereby made to the Director of .Building and Safety
for a permit. subject to the conditions and restrictions set forth on his
application. a,
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to,5& shall; indemnify
& hold harmless the City of La Quinta, its officers agents and:.,employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of: ,issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have. read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives' of this City to enter upon
the a6ove-mentioned property -for inspection purpos S. s'
VSignature (Owner/Agent) 1 Date a�
7.
's BUILDING PERMIT PERMIT# CONTROL#
}1tii9_+f39
PATE VALUATION �1�ya��(� LOT TRACT ;4QL �q
JOB SIIE
ADDRESS 7�.a-!�,ltrl.1tl�i1[u1[e�i
APN
OWNERS
CONTRACTOR DESIGNER ENGINEER
�. }.p �• �y A p �yr� C y r!l.i�i.l,"0.►,YT[`it•.ii�ri.'1.i,,d,i.i.e°eAa..'l,.i.i�i.W.�
"AP$iAL,Ptwl:fHO.N 4Ec1N\
4100 ly1dC ARTHUR 8Ld7r[200
4100VAC lR :i4VR BIND #2
t`a :V>i 1'I31sr�1CH CA W660
NEWPrJ.i2:1',Bl:AC3 C.A. 92660
CB L Pr 15A3
USE OF PERMIT
.%D - PLAN 447R, LOT43ti, 1 FAU111 DOES NOT INCL=E I31.C"iCK WALL
Olt !'CzOL, PLAN CHFCK FM RLDIUCL13 BY 75"/'o'k Olt MU%T.PL8
]ISSUANCE Sxf' SAME PLAN TYPE.
CUSTTG I CON. TrRUCTION 3.7.10.00 Sig"
MC 1%C14JP f 10 205.00 sr
QA.11<'t.CMiCARP0 1' 581-00 SF
IF!n�3 1i1Y.92�KA A.+� 1.i.9 T..�.4� G tY�7./. fi�J�Tt .9Pi
303,123.10
VERNOT FEE SUMMARY
CONSWLIC'1'ICNFEE 101-000-4113-000 51.363.50
PLAN CFWIII� FM +0! 18 5^74. 0
MWftAT WAL FEE 101400.421-000 51.11.53
ELECTRICAL rfi8 $4.1-iltiGi-�20-000 �1>S.9'r
PLUMBING 1»Ems. 101 00-4194*0 S2t0.30
377ONO MO 'ION VES - RE,1131D 101-000-241-000 S320.3'i
GRADING MOIL -0000-423-000
�pADIN�� f �9�t�y �+7-T•
225,000^443-34 1�%�LKI.Vtii .
AftT IN PU RL1C PLACMS-1Ea113 701--000-235-000 5.507.81
e�
S
i � '�►°°s��1L b'".t)T1�'�`�,$.k-".f'1:0N AND PT_�.�1N r;l"1PC,!(
Prim' ,ESS PRE -PAID FEES
•I.00
SEP''2 9.1998
Too At, .PFIRNIff FEES DUE NOW
$8,74moq
.J1TY OF LA oU TA .
:RECEIPT
DATE
Ti
D
INSPECTQR
"F%ALED
G .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
����_�� !/�
Underground Ducts
Forms & Footings
�_ �'
Ducts
_ _
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck / ..
Exhaust Fans
O.K. to Wrap
2
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
<
Final
Final
Z�
,62
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
_
Waste Lines �Q��� �` �!/(
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�d2..$' — �f� �G�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
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
Date 9/17/98
No. 17752
CERTIFICATE OF COMPLIANCE
APN # 769-560-036
Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc.
No. 79-915 Street Tangelo
City La Quinia zip 92253
Permit #
Log #
Study Area
Tract # 24890-3 Lot # 36 Square Footage 1
Type of Development Single Family Residence No. of units 1
Comments
Under grandfather agreement - 3,710 sq. ft. (The Citrus Course)
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 and that'bi�iilding
permits and/or Certificates of Occupancy for this square footage in this proposed project may_, noww be issued' "'
Fees Paid B CC/Wells Faro & Co./Manuel
By g
y'
Telephone 564-4475
Name on the check
4
By Dr. Doris Wilson
Superintendent
' /6
Fee collected /exempted by Juanita Green Payment Received
$628.00
Check No. 0643.036924 .
Signature
q NOTICE: Pursuant of Asserh6ly Bili 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
tolled 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