0007-301 (SFD)�i
`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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7J3431 B 03431120
Date Signature of Contracto
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).
( ) 1, 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
performsp�rr ce of the work for which this permit is issued.
(,);.-nave 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 cariller & policy no. are:
Carrier ZURICH IMS.Ca Policy No. W)i, 6034965
•(This section need not be completed if the permit valuation 4.for $100.00 or less).
() I certify that in the performance of the work for which Phis 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I s II rthwith comply withA o e pr I r.
Date: Applicant..... o `.1 L_,
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, indemnity
& 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 propertt for inspection purposes.
Signature (Owner/Agent) t�-K.�"` 1' 17 Date C
BUILDING PERMIT PERMIT#
OW7 .
DATEVALUATION LOT TRACT
t0o,0 i2.tx0 26 2€334•5-3
",
f A. e)
JOB SITE /
APN
, 3�,t
ADDRESS �ji1. 8Ar4.I.O,)A0]%ff EAI
�dV
OWNER
CONTRACTOR/DESIGNER/EN (NEER
L D: NI=P1v1 MT C9OR.PORATTOW
KSL DEVELOP dT CO:R11013AXION
55-920 FGA.BLVD
55.920 PGA DLVD
L.A QUII rA CA 92253
L.A. QU@PTA CA 92253.
(760)W.7166 CBIN 4676
USE OF PERMITr
0LEFV V M IY TA
SWD. LO'T:26 PLANS DALT• PMMIT DO&S NOT INCLUDE BLDC:K WALLS
OR P0047W PLAN CHECK F99 REDUCTION FOR MULTIPLE ISSUANCE .
OF SAME PLAN TYPE.
CUSTOM OM CONSTRUC" TION 1,600.00 SP
1:CS'I`1I4ATED COST OF COXNTR 1DC'n0N
.13OA72.00
PETOM tl'`.li�I1.9UAO Y
CONSTRUCTION FEE 101-00041"00 $740:00
>"
PLAN CHECK FEE 101-000-439-318 1�138.`7tJ
r " Thr
MECHANICALF'EE 1.01.000-421-000 $130.so
9LX TRICAL FEE 10.1-000-420-000 $99.96
PLUMBINOFEE 101.000419-000 $191.00
STRONO MOTION fW = RE.51D 101-000-241-000 $13, 091:
;,
ORADINO IRE 101.000423.000 $20.80�_
.
DEVELOPER IMPACT FEE $1,80'1.0.0
SM -TOTAL CON-MIX`TION AND PL" 0,1.11,. Y
$3,248.18
LMS pRr_PAM I.TM
$0.00
MAL PERMU FEES DI?E NOW
RECEIPT
DATE
BYE /
DATE FINALEDINSPECTOR
IN
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE -
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs I
- _ GJ
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade I
_
Return Air
Steel i ;
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap 1
F.A.U.
Framing }
Compressor
Insulation I
Vents
Fireplace P.L. i
Grills
Fireplace T.O.. - I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party,Wall Firewall )
Exterior Lath, I
Drywall - Int. Lath i
1ir
1
!
Final
1777�, ' �s
Finale i Z— , ��/
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Racks
Electric Bond
Footings I
Main Drain
Bond Beam I
Approval to Cover
!
Equipment Location
. t
Underground Electric
-
1
Underground Plbg. Test
Final )
Gas Piping
PLUMBING APPROVALS
I
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping )
Plumbing Final
Plumbing Top Out i
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
1 Lateral I
Sew#
Pool Cover
ew Connection 1
Encapsulation
s Piping 1
Gas Test )
Appliances
I
-
Final
I ..-
Final
Utility Notice (Gas) )
ELECTRICA_L APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service t
Sub Panels )
Exterior Receptacles
G.F.I. )
Smoke Detectors
Temp. Use of Power
1
Final,
Utility Notice (Perm)
COMMENTS:
Certifica to of Occupa'ncyC
it
oLa Qunta
Buildiii. an i Safety. De artment MoF- ti9
p
This Certificate issued pursuant to the requirements of Section- 109 of the Uniform-Bui/ding Code,
. certifying that, at the time. of issuance, this structure .was in -compliance with the` .various ordinances
of .the City regu/athig building.construction or use. For the 't6116 wing:
BUILDING ADDRESS: 4.91.4.68 AVENIDA ,0.BREG.0N
Use Classification: SFD Bldg.Permit -No.: 0007-301
Occupancy Group: R3 Type of Construction: VN Land Use Zone: TC
Owner of .Building: KSL. DEVELOPMENT CORP
Building Official
Address:
55-920 PGA BLVD
City:
LA QUINTA CA 92256
By:
.KIRK KIRKLAND ,
Date: 12-11-00
I POST IN A CONSPICUOUS PLACE