9902-077 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chanter 9 (commencing with Section 7000) of Division 3 of the Business and
Prdtessionals Code, and. my License is in full force and effect.
License # Lic. Class Exp. Date
R 4/30100
ate.3 � 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).
( )• 1'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.
{,/) 1 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.
(This sectio'n�neeYno be completed if the permitvaluation3$100 030 or less).
O 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
Cede, I shall forthwith comply with those provisions. -
Vl5ate: -_e..4 /h `: Applicant /.,+•F� - ' R (� __. "»- •../
7 7J I
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for. a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectiontpurposes. a
'
,Signature (Owner/Agent) '-* * .--�' J" r- " Date* � ,[f
P
BUILDING PERMIT PERMIT/t
DATE VALUATION • . . LOT / - _ 90Z0.7ii7. lt' TRACT
JOB SITE !
A
PN
ADDRESS.-- ... .
769-520-002
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CAPSTONES GOLX NEST LLC
SHANNON COMMUN11 [ES CE CAL,i:iR.,1NC
200 E. WASHINCC0N AVENUE
200 E. WASHIN<"rTTf1N AVE., 4100
LSCON.DIDO CA 92025
ESCONDID0 CA 42025
C760)839-13238 CBLO 413
USE OF PERMIT
1.0T 64, .PLAN 2-2A. -3FD- PHOT DOES NOT 1WJ T7DE'BI,OCk WALLS
OR POOLS, PLAN CHECK FEE 1.1, REDUCED 75% FOR Ivf[;f%'1'Tl L
.4P11T INC, Or S'ANfF PLAW TYPE,,
ClS:fOMCONS'fRUC"1'I0*N 3.,74$.00 SI:
PORP, PATIO 793.00 Sr.
_
QAP.AGFXARP0RT '738.00 5F
EYT1I1+3XfED COAT OF C'ONY7'It•[iMi{)N
r
3241,786.64)
PERMIT FEESUMMARY
,
CONSTRUCTION FEE 101-000-418.000 $1,413.00
PLAN Ct E.CK F FM 101-000439-318 $286.38
MY_Y HANICAL FF3r 101 -000 -421 -WO $111.00
ELECT'Rf.CAL FEE 1:01 -000.4120 -WO $rd.12
PLUNIB INC, FEE 101-000-1114.000 $20.73
WRONG MOTION FF9 - REBID 101-000-241-000 $32.08
G:RAt].INQ FEE 101-OOE)-423-(100 S -,V,00
1Nb'iia.3`1`ATJC1`t)R:E'F9H, 225-0W443-342 $6,000.0
ART ENPUBLIC PLACES - Ri?SW X101-000-2554= $551.97
SU134GI:AL CC`NS+r-RUC;' ION AND ELAN CHECK
TOTAL PF RA41T FEES DUE NOW
$8,1144.310
RECEIPT ` ��— c�7L
DATE r
BY r ,
L�E�i D
INSP CTQ
INSPECTION RECORD
^ OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -
Underground Ducts
Forms & Footings
Ducts
Slab Grade j
Return Air
Steel
Combustion Air
Roof Deck Q
Exhaust Fans
OX to Wrap
F.A.U.
Framing /
Compressor
Insulation 4zVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath IM Q-74-4—
Drwall - Int. Lath
Final
Final Z A z _ -POOLS-SPAS
BLOCKWALL AP ROVALS
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 g , G'
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Final
Udllty Notice (Perm)
COMMENTS: