9809-022 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed ,underiprovisions of
Chapter 9 (commencing:with Section 7000) of Division 3 of the Business and '
F rotes§i6nals Uode, and'my License Is in full force and effect.
License # Lic. Class Exp: Date
i4 "f�is Its X13 f�i
/ate f%/ 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:
( ) 1, 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.
C1GAlr% C"A041,35N
(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 Section 700 of the Labor
Code, I shall forthwith comply withthose prov Bions.
"
VDate:' / Q Applicant 1, A -�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on h
is
application..
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit'work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify.
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application. becomesnull and void if r,
work is not commenced within 180 days from date of issuance of such "
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City; and State laws relating to the building
,construction, and hereby authorize representatives of this City to enter.upon'
th above-mentioned property for inspection purposes.
Signature (Owner/Agent) t1 uw / • �� - Date a
BUILDING PERMIT PERMITyCONTROL#
DATE f // VALUATION I OTW, TRAnT 8;�.4�
I '/� 5;. YL�1V�n. JOB SITE'
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CA_P:j"TAL PACU IC HOLDINGS, WC;
C:AIRITx°AL PACIFIC HUNIE$ IRC
4100 V.IAC AR.i'146'R. Bi..VD ;#200. •
4100'? AC AR114UR BLVD6200
NEWPORT R ACH CA. 91660
NEWPORT REACH CA 4260
(949)622-8400 Ci39. O 1_503
USE OF PERMIT
SINGLE I;ANi.iI.Y'i-WFLI..I-NG
SF.D - PLAN 3CR. LOW 21. PMvIiT DOES 140T INCLUDE BLOCK WALL
OR POOL. PLAN 04EC.K F.E IREUUMD BY 750A VOR M.Lff. TIP1..N ISSUANCE
OF SAMA PLAN TYPE,
CUSTOM COAWSTRUCT10114 3,4W.00.SF
PORCi fid MO 268.0 .r•-
CifitZACi rA t3 0T2'Y' 5$9.00 SUP
ESTIMATED COST OF CO1 ST' UC ION
279,963.80
IP'E:RM: e VJEEF SUMMARY
CONS'TltOC TION HP -E, 101-000418-000 $3. i9:5t7
PLAN C;x}Er,K FM, 101-000-439-318
MEC i3tA:NTC;AC,1� F 101-000-421-000 S.5.0
fiC'1 c" Cit tc At. Mfz, 1U.Ir900.4120-000 5108.28
P1.0 Y1k311.Vt"a .1, -EE 101 -OW -41,9-000 S.180.4W
STR.OW 3 'A4.01 011N t T, - AVL81,f1 .00
0R,'VtXNQ FW3 :I01-000.423-000
t.iN1.
PRAS`T`PUCTURE 1 I. 006 1-0064B-142
,ART 1N PUBLIC PLAt ES - td�StlC 014)0-255_000 $44.9.92
S M-"IT(VAL� CONSTI UC'II(3N AND PLAN CHECK
; P
2_9 1998
SEP .1*0'.rA:[.'FPiVU C I?FI; DUE. NOW
S..4,490.83
QUA u
`
11 T i - #`r iti s
�DATEFINALED
RECEIPT
DATE
BY /
INSPECT
G
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs %
Underground Ducts
Forms 8 Footings
(i{
Ducts
Return Air
Slab Grade= -� �/
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap=�-'�
Framing
��
F.A.U.
Compressor
Insulation
Fireplace P.L.
Ll _ o
a�
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
o►
t
•
Final
Final 7�_ 0�
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�—
'�5 `T �
/ol�
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 C? -7 - q
��L
Final
Utility Notice (Perm)
je
•w
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La_ Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date - 9/17/98
No. 17755
Owner NameCapital Pacific Holdings, Inc.
v
APN # ' 769-560-021
Jurisdiction La Quinta
Permit #
No. 79-950 Street Tangelo Log-#
City. La Quinta , Zip 92253 Study Area
Tract # 24890-3 Lot # 21
Type of Development Single Family Residence
Comments
Square Footage 1
No. of Units 1
Under grandfather agreement - 3,400 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: • I
t
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE'
This certifies that school facility fees imposed pursuant to Mitigation Agreement i iti the °amount of
628.00 X 1 or $ 628.00 the property listed above and thai building
permits and/or Certificates of Occupancy for this square footage in this proposed project may - ow be,issued
r4
Fees Paid By CC/Wells Fargo & Co./Manuel Ttlephonpp'
✓dry � L
Name on the check �►i�`,-.' " r
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by
Signature
Juanita Green Payment Received $628.00
Check No. 0643036924
NOTICE: Pursuant of Asseb6ly 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 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 - Appficant/Receipt Copy - Accounting
V