9809-018 (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
F''&6§e ionals lode, and My Licehse is ih full torce and effect.
License # Lic. Class Exp., Date
74074.5 B 9/30/99
ate j -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. ..
CICi�A'�tA C4(f4,135'4t
(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 3700 of the Labor
Code, I shall forthwith comply with those pr isii�on; /
vKate: � Applicant��E 9 '"� l _'.=_�_
Warning Fai ure 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.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.Y•
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 inspections purposes.
/,gature (Owner/Agent) fAA N �� d ��c e Date „C_eGA3
PERMIT�#CONTROL#
BUILDING PERMIT
DATE , VALUATION �` 71;,'9. 0.411 LOT ?i7 TRACT '2814114
. 14 e r
JOB SV 1APN
r
ADDRESS 9-95.5 TAI�Io.i+ELO
_ 76.9-560-037
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C.AKrAL PACIFIC HOLDINGS, D4C
CAP.: rAd, PACT' C f-IONrIES :INC
4160 iv1AC:f*,KINUR €3LVD 0200
4100 !IAC e RT14UR 8LXT- li200
NP,W ORT BEAC3.1 C.A. 92660
NEWPORT BEACH 'CA 92660
�:s49j622-8 100 CBL# 1503
USE OF PERMIT
SiNGL.E FAMILY DWELLING
WD - PLAN 2B. 1i OT# 37; PERWT .JOTS NOT INCL.UDE DDOCK WALL
OR POOL. PLAN Q.ii(�FEE R DUC:6D BY 7_1%.FOR na(1:i'ir<a,
ISSUANCE OF SAMEPLAN T"itP€i.
CUSTOM COI'uZRUCr.10N 3;306.00 Sr,
PORCHIPA IO 2901%) IF!
(JARAOR)CARWORT. s.W is>:
:ESVIy1A,Ti eD COST OF CONWRIXTION
27.1.830.40
PFA1=e�::11' YET SUMMARY
CONS17'RlICTfON FIX 1.01-000-4113-ifi O 51.24.1.50
PLAN C,' FCK. FTF 101 -WO -439-318 $251..26
ii1I:C'rirli+( t'��r`; I*"E 1d)a-1?ii�-42I:-ow 5105.00
L1.CTIUCAL FEE 10I-000-440-000 $75}3.91
PLILIN kiIN1L11TFE 101-000-419-0(10 $180.50
STROMI A#-(YrION FEE - ?tESID t 01 N)O-241-000 Vl'/.19
0R.W[NCf FEE 101-000-42.3-040 32b.0U .
.114FRASTR UC T U 9 FOE `23-000-4141-342 $6,000.00
AJR7 iN'PUBLIC OLAC` S' - RESM 1,111-00(1.2.55-000 $429.70
t;
PAID'AL, i 0N, STR'UC"�'I(JAt'E�le D PLAN C.�HOC
$8,439.06
LESS PRE -PAID FEES
$0.00
;.• " SEP 2 91999
• t5 '1'OTAl., PER.M;IT F:L+:ECS DUE NOW
W,439.06
e
RECEIPT"
DATE..
BY ✓ iy `-`
DA E FINALED
INSPECTO'R//
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs �(' —q
Underground Ducts
Forms & Footings
(,C_
Ducts
Slab GradeU
�� 4�41�i
ReturnAir
Steel
Combustion Air
Roof Deck
_J _
Exhaust Fans
O.K to Wrap
_ O % -
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
_
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
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
! 1;Z5��'1 G
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)l�_
/
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
Utility Notice (Perm)
�Cl�
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515-
CERTIFICATE
60-771-8515CERTIFICATE OF COMPLIANCE
Date 9/17/98 APN # 769-560-037
No. 17751 Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc. Permit #
No. 79455 Street Tangelo - Log #
City,La Quinta Zip 92253 Study Area
Tract #'24890-'3 Lot # 37 Square Footage 1
Type of Development ' Single Family Residence No. of Units 1
Comments
Under grandfather agreement - 3,306 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 huildirig
Permits and/or Certificates of Occu anc ,for this square footage in this proposed roJe.c>now be issued ,
Fees Paid By CC/Wells Fargo ,& Co./Manuel TeKephone :564-4475
Name on the check `ti•=,�.
By Dr. Doris Wilson
Superintendent r t.•.: ,
Fee collected /exempted by* Juanita Green . Payment Received $628.00
Check No. 0643036924
Signature
NOTICE: Pursuant of Asserdbly 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
<A collect them on the District('s)(s') behalf, whichever is earlier.
r
Collector: Attach a copy of county'or city plan check application form to district copy for all waivers.
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Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
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