9809-017 (SFD)y
I: LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed underyprovisions of
Chapter 9 (commencing with Section 7000) of Division 3 of tl le Business and
Professionals Code, and my License is in full force and effect.
License # Lic: Class Exp. Date
740745 9/,310/90
ate Si nature•of Contractor d - `�
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.
(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.
C1d;NA, CWA 135 i
(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,
1 -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
subieci to the workers' compensation provisions of ti 3700 of the Labor
/2C de, Ls�all f'o/rt�hw��iith comply wit �t ose p vision
te: ( 1 Applicant � �� I l-, '< E� .rM.Q
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 cosy -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. f
1. Each person upon whose'tiehalf 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'lssuance'.bf 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 purpo S. k
/ignature (Owner/Agent) VU ` �{ Date
BUILDING PERMIT PERM' gW9_0'17 CONTROLk
t
DATE I
VALUATION $254.511.50 LOT 34 TRACTJOB
Gj
SITE
ADDRESS , M-9 65 TANCr�il.ei
APN 7 '0 �9 i83S
O.WNERA.y{.
CONTRACTOR/DESIGNER/ENGINEER
dn:tittiC, I10Jy"iirGS� INC
CAMAL PACIFIC 414M ` M�C
4105 .ivll.0 r' 1.PITHUR.BtLVD is20
41001Uy AR`1 HUR BLVD 4200
NEWPORT PORT BEACH C',4 92660
Nl:_RrPf;)StT ULZAC14 CA 92660
(049)6224400 C 3L. I M3
USE OF PERMIT
STA GLE FA%:1l1.Y.DWE` LIN..0
�
3 iD - PLAW 1A, L0T38, 'P:3~ti.b``v1rF DQ 511,00 MLiiDEB3 'tC',h/An
t' k( RPOOL. ;PLAN CW_,CK FEE'itEI; UC:lii71?Y 7$0,re FOR Mill: `3 WL E ISSUA.r.'(S
OF AME P1. AN '13'P6,
CLS'TOLIV) COINS P. RUCC1 YN 3,060.01) Sr
PORC FWAT10 1:8.06 ar
t;�At2A� lGAt2.1'C?lt"T.' 565.(h) S'F
.gESTILo'�F.�. ED COST OF i.:tJAVtY,iRUC Y I OINT
.g,p� 7►/[ t
��B��n g LL SUMMARY
MT
CO-N-S:iRUCTICYN FFX 101-0016418-000 $1.182`2.00
Ftp,A��tstc`H�El+v��K r1+t1^ 101-000-43g-:?1�$249.99
.evlr.o�F*1b\4\ At. A3L � A:+7i 101-000421"000 D�J..riJ
E-1sECf'k1C:AL 'FEE 101, -OW -11120-000 $1701.22
LTJMB1N(3k.kF 101-00fi-�t19-Ui3f) $I f3.S0
511.C,mv,.M-0vow'nm pu sm 3o1 -i3 o-243-000 ms >o
GRADING FM 101.000-423-400 520,00
INFRASTRUC'TURX FEE 225-000-443-342 S5.625.35
ART ENPC1BLIC PLAN - 701 -000 -25? -0010 3f3t�:dii
yREST4
CON AND PLAN C m-cK
S7,934.29.
,UCTT,t7N
LESS PRt-PAW FEES,
$0,1w
SEP 2 91998.
l�"1' , ..1a1a 1 1.T 'M"i?iHj,51:1)i� NOW
N/ (�
$7 29
Lg OUA NT+
RECEIPT
DATE
BY
D T FINALED
INSPE OR
f'`
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs l(>_ �Q/
Forms & Footings (�
6C
Underground Ducts
Ducts
Slab Grade
_
Return Air
Steel
Roof Deck
e
/'�`Q
Combustion Air
Exhaust Fans
O.K. to Wrap _ _
Framing
����
F.A.U.
Compressor
Insulation
6
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final ��
BLOCKWALL APPROVALS
Final
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
Waste Lines _
Gas Test
Electric Final
Heater 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:
Final
Utility Notice (Gas) v
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 ►�
4,
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated .760-771-8515 ,
CERTIFICATE OF COMPLIANCE
Date 9/17/98 APN # 769-560-038
No. 17750 Jurisdiction La Quinta
Owner NameCapital Pacific Holdings, Inc. Permit #
No. 79-965 Street Tangelo Log #
City La Quinta Zip 92253 Study Area
Tract # 24890-3 , Lot # 38 Square Footage I
Type of Development Single Family Residence No. of Units 1
Comments
Under grandfather agreement - 3,069 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 abov a3ta,-that building' -'e.
�g L
permits and/or Certificates of Occupancy for this, square footage in this proposed poj,ct.rnayweTssuedi�..
Fees Paid B CC/Wells Far o & Co./Manuel ' 0 ``� c .
"'+ �.elzpho>i�� t564 -4475,x*
y g
Name on the check "•.
J' L�
i Ml� t
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $628.00
Check No. 0643036924
Signature
NOTICE: Pursuant of Asi ff ribly 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
collect them on the District('s)(s') behalf, whiciever is earlier.
r� 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
L4