9809-021 (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
Prrofessionajs Code, and my License is in full force and effect
License # Lic. Class Exp. Date
,r
7407414 B
,,Date 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 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.
C. 0MA C 4041352t-
(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
subjct to the workers' compensation provisions of Section 3700 of the Labor
C9de, I sh ll, orth ith comply with those pro sions.
,Date: a pplicant 11 23
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT- Application is hereby made to the Director of Building and Safetyy
for a permit subject to the conditions and restrictions set forth on his%t
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct!I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the/above-mentioned property for inspection purpos s.
,Signature (Owner/Agent) Date CO
PERMIT# CONTROL#
BUILDING PERMIT
DATEVALUATION . LOT . _ TRACT 02,
7 -
9- y p7 p�
JOB SITE
ADDRESS7-9-944)T1NG"E�
APN
764)" 6"2.6
OWNER_ -
CONTRACTOR/ DESIGNER/ ENGINEER
Cl"TAL PAIcIC HOLDINGS, i -NC
CAPITAL P CIFiGI1-140ES NIC
i1v"0 A � t. `rtts'� t LV J iiis20�i
4100 tlMC ARTHM BLVD t►200
NEti1/1)C)XP REACH , CA 92660
NEAYPfJ.1C1' ;R ACH CA 92660
(�34?�jb?i-te4(J0 G:ii;, 1503
USE OF PERMIT
s%N'CT. x FAM&I.,Y DWELLING
V, D - PLAN 4C P, :LLM#20, PMAT DOES NO N Tri►DIa DLOCK NV ALL
Oil &'c')+7L. PLAN CH C:K I' 1:,3.RI;DUCED BY 7YA FOR MiX1 �.fiIL6 ISSLiANC16
OF SAMP, PLAN'P11K.
CUSTO$e CONSTIWCTION 3,730,00 :;F
Pi?1't.0 1-ifPATIU 9-F
0 ARAQfifCAA3P0R, i' 581.110 18
ED COST iVl3f C2N4TT UC•.�'�.Im�`d
fit / q�. y �{'�'r }��/,qy p��, ��yp,:�3%TIMI�#:':
4. �JR1'� IT D� .Y� E S V �•.F�`IA II
PERMIT
COWSIRUCT'ION.F.Et, 101-W0419-000 S1,3S:3.St+
FLAN 01—Er?a'..PUP. 101.000-439-318 $274,50
AlMIANICAL FEE 101-000-421-000 �:i13.Sti
itrl-CrIlIC-AL TE, a _ I .u1# -420-000 3iyR.ti7
PLUMB) NO FEE Itit-041()-419-1)00 $210.50
STRONG MOTT(,)N 111-K,- RFS10 -a! 61 -CCI'. 2 41 _(a
GPADING FEE to) -000 423-000 $20.00
INFRA.s r.Rt,?Cs�'[3i2k: m-?" 22S4*0441-342 561,000.00
AftT IN J`�i,iL�uc T ,otCFS - l2Esw.• ,y. 000a 254-(,10{9 $5177.81
PASAURTALAND PLAN CHRI
$8,707.09
2 LESS PRE40-AdD FEf�
$0.00
SEP
S
. P011 Dui: NOW
OU,i�a € ERMM,
1,1��1 e'
JI A
j
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 — t/
Exhaust Fans
O.K to Wrap
_
F.A.U.
Framing —
Compressor
Insulation
Vents
Fireplace P.L.
Grills I
Fireplace T.O.
Fans & Controls '
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 2 R
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 S
Gas Test
Electric Final
Waste Lines —
Neater 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
Appliances
Final
COMMENTS:
/0 ' Z2 — 'l V XA
%O-d-1*1111 , i m S
_
Final
Utility Notice (Gas) -7--2-5 -q
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
t
Final
tltilly Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 9/17/98
No. 17754
Desert Sands Unified School District
47-950 Dune Palms Road,
La Qui>nta, CA 92253 1"
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameCapital Pacific Holdings, Inc.
APN # 769-560-020.
Jurisdiction La Quinta
No. 79-940 Street Tangelo
City La Quinta zip 92253
Tract # 24890-3 Lot # 20
Type of Development Single Family Residence
Comments
Permit #
Log #
Study Area
Square Footage 1
Under grandfather agreement - 3,710 sq. ft. (The Citrus Course)
No. of Units 1
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 ilr\the,,arrount of
tea.
628.00 X 1 or $ 628.00 the property listed above ar'd that building
permits and/or Certificates of Occupancy for this square footage in this proposed projlect may nJ� be issued �;
o.
�: , a
Fees Paid By CC/Wells Fargo & Co./Manuel TeM-phone �564��4475
Name on the check
By Dr. Doris Wilson rN,;t.<•-
Superintendent
Fee collected /exempted by Juanita Green Payment Received $628.00
Check No: 0643036924
Signature
NOTICE: Pursuant of AssemV Bill 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 authorizedto
collect them on the District('s)(s') behalf, whichever is earlier.
iCollector: 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