9809-023 (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
1-rOM9916t1al5 uoae, and My LICense isln tun force and effect..,
License'# Lic. Class Exp: Date
Z740745 r, tilt'
te` / �'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).
O 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.
(y) 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.
CIGNA CA04133;
(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
subje*ct to the workers' compensation provisions of S�'3700 of the Labor
.966e, I sh II forthw-th comply with those p ovisl 4s.
Ybate: r ApplicantFF ✓ �'
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. g,-.. ,
1. Each person upon whose behalf this application is made & each ersoniat
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;findem;ify
& 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,�yoid 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
correctr`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
/thabove-mentioned prope tyfor inspection pur oses.nature (Owner/Agent) ��'` c Dated`
-__7�/j__�� L
PERMIT # CONTROL #
BUILDING PERMIT 9NO04)23
AAy�qq.;i p
DATE VALUATION ��7� fL�ffi1 c3�! LOT ? TRACT ��Q'�8.) 9
JO B SITE
S 79- �)t, Ai Y bl+ d
ADDRESS
PN
.7694%0-62.2
OWNER.
CONTRACTOR / DESIGNER / ENGINEER
CAf'17.1'.Al, � ACIFIC. II.OL131NOS, T%C - .
{r-AffFAL PACIFIC F ORFS ]i•I(I"
4-1001%4AC AR'1THuR'SWD 1200. -'
4100M.Ai AXftiUR BLViD #200
NEWPORT'BEACIJ CA 92,660
NEWPCaRTB)S.r1CH CA 9-21660
(949,Y,72-8400 CTA114 1403
USE OF PERMIT
�11ac,i.,k3 %A;viti.e�` f�tN'BL.[,1tuc;�
.4"-0 - PLAN XR. LOT#22, PUMt 10OFFi -NOT MC LUDE BLOCK WALL
OR 100L. PLAIN CUEC'X.bVfsR.hDI C ED f3Y 75% FOR M[I %TU0LI;13113U-ANCA.
OF SAiMHE PLAN TYPE.
C iSiJ .t �1i i C41NSTRUC„] ION .3,306,00 V
PC%,tCfVf'A::rf0 290.00V
GARA4i,EaCARf`XDWf 535.00 SF
&STINU► D C08 €as= CONISTIVVIC11��N
�17� g y
gy7p y VEE
P L'F.,IEV.YO.A. VEE SU1�iI�A kRV
.
CONSTRUCTION 1"Fli 10.1-000-418-M S1,241.. +0
PLAN C'4'EC1a FFE 101-009-439-318
NIECRA19IICAL rI S l0Y-OOtl;42;,-000 s.105,00
:E_LLC.:"13 MAL FEF: o$ -Ofd- i2aii0o X18 (.9,r
I'LLWBI.NG FET I01-0000-419-000
S' '1 ONG jb40`,i'ION T:1 - RMSM 1014M-241-000 $27.19
GILADINO ME E 10.1-000-421-000 $20.00
:INFRAS11RU(:113121;: TM, U5.000-.443-342 0600.0
AWr IN PUBLIC PL r4CE8 - kg' ,= 701 �000W255-OWO $429:70
81�1'a-"[Y'3.'1A�,'r ill �"T' UCII-ON. NNOM ANCHF-C
���35',tif►
r` LESS :1311,-PA1DIFE S
'
KOOPAILJ
SEP 2 91999 T074VL P M:1TF:ECS DUE :l OW
S8,439.06
jA� t
tr�)
RECEIPT
DATE kx'_ j'
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
Exhaust Fans
O.K. to Wrap
—901
F.A.U.
Framing
- -12
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 Com.
Final -
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Q.K. for Finish Plaster
Sewer Lateral
9p
Pool Cover
Sewer Connection'
f'� '
Encapsulation
Gas Piping
Gas Test
77 '? zi1
Appliances
Final
Final -G
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)�G�Gj
tic_
C
COMMENTS:
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Qui><nta, CA 92253 "
Document Cannot Be Duplicated 760-771-8515
Date 9/17/98
No. 17756
CERTIFICATE OF COMPLIANCE
APN # 769-560-022
Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc.
No. 79-960 Street . Tangelo
City La Quinta . zip 92253
Permit #
Log #
Study Area
Tract # 24890-3 Lot # 22 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 thaaii�bu.iid'ingzf' x'
�., ..._ (%
,
permits and/or Certificates of Occupancy for this square footage in this proposed project miy4)` w b&issued '1;.`r
\
`- "
Fees Paid B CC/Wells Fargo & Co./Manuel
By g
Tele`p pone 5 ," 44'75
F %.
Name on the check
d
By Dr. Doris Wilsons
-
Superintendent��;;.-
1f�., ,
Fee collected /exempted by Juanita Green Payment Received
$628.00
Check No. 0643036924
Signature
NOTICE: Pursuant of Asserbbly 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 fromillhe date on whici the building or installation permit for this project is sssued or on which they are paid to the District(s) oe to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
f' 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
v-