0312-015 (SFD)LICENSED CONTRACTOR, DECLARATION
IIS 7e ebur affirm under penalty -of perjury that I am licensed under provisions of
�.Cnapter 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
y ' ` 7�35ii1 131 Cl6 luc fes; i�1111014
Date Signature of ContractorC�
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; c jnstruct the project (Sec. 7044,^ Business -& Professionals
Code). t
( ) I am exempt runder Section B&P.C. for this reason
Date- - —Signature of Owner
r <,
WORKER'S COMPENSATION DECLARATION
I ['; _
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 . EXTEXPi Policy No.'
(This. section need not be completed if the permit valuation is for $100.00 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 ilf/Ehould become
subject to the workers' compensation provisions ofSection 3700 of the Labor
Code,,l shall forthwith comply with those provisions./Ij
Da e: 1=' • , , • *l' Applicant ^r✓- bi �(I
Warning: Failure to secure Workers}Compensation coverage is unlawful and
shall subject an employer to criminalipenalties 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.,y
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
1correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of th'is.City to enter upon
the above-mentioned property for inspection purposes.
`.Sign to bre (Owner/Agent) ;w ~j�J�?y- D
BUILDING PERMIT PERMIT /t -
DATE VALUATION LOTS, TRACT
V 29147-1
JOB SITEAPN
ADDRESS'. 7• �.� I 0,1q F 4e� A
OWNER
CONTRACTOR / DESIGNER / ENGINEER
•Vd',1M(sr.s1£:Ori,' oTman, .T.LC
XA:fi-tl'i1.1 A COINTSMUC310,14 19C
61 _d711 AI TTC Xul
78.070 CAML
LA QTJ.Il f Cly 92253
Y.,Qf1'3WTA. CA 92233
CI G11}564-4832 CRIA 3237
USEOFPERjMITJ! .}���j
�°.� �\
S�.�J�fX:I�ir�AVJ, E- .Z✓ .�.f7JDTG
VVD • L f 39, .Pi;.l►N 3E1, PERMIT DOES L40T .tNCL,U.DX BLOCK WALLA
Pool.z UPA Oft DRIVEWA APPRC1Pi H, 7% I EDUC T11014 TO MM C11ZC--1:= - --
FEE DUE TO MU:I,I'IPLE ISSUta[C:E O SAME Pl kH TYP9
6CUSTeN CONSTRUCTION 069.0091111
PORCHtPATIO 986.0C SIS
CI,Ad1/ C1;�fC,�TtT�OR.T 11.00 SF
F.
PWRW F 1; SIR SaTMMA RY
CONSTRUCTION ME 1101-000-418-000 $1.721,00
FLAN CHECK X'Ei. 101 -^00f) -r139 -?t I g $97.017
r
1a ECHMIC;AL FRE 101--000-421-000 $149,50
In -Z CTRICU, IFEk 101-000-420-000 $246.64
PLUMBIND YRF, 101.000-419.000 $2331 I'm
-
ST1`ONG MOTION M - I'.k1111Ill 101-000-241-000 $40.88
031WINO FIN 101-0130.42.3.000 515100
iJM:tTt:LOPF..T IMPACT FV,
ART IN PUBUC PLACES - r:. 111 270-000-445-000
F.j3:�:t-`1'C}i�,t.•t"�A'1�R1�Gi1C?k? t��fi.4.;t 1'� C1��ti.
� j,isi�1.4t4 ,.
e I YET -8. DUR vow
L
y1UINTA
RECEIPT
DAYS.%
Y �Jf
PATEN D
INSPE
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
_
—/� �v�� _
Exhaust Fans
' O.K. to Wrap
,�
F.A.U.
Framing
Compressor
Insulation
Lei
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 6
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
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
ly
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVA S
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)
COMMENTS:
Jun 04 04 09:38a John Read
760-777-8789
THE S UMMI T A T P GA 'WEST _
TRANSMITTAL SHEET
To: Kay — City of La Quinta Building From K11y Koger
Fax: -777-7011 Pages: 1
Phone: Date: 6/4/04
Re: License -Changes CC:.. ' Fiie
❑ URGENT ❑ FOR REVIEW ❑ P1:.EnSF C01FML:NT
❑ PLEASE REPLY ❑ PLEASE RECYC1,1I`
Please find the following permit numbers that are to -be changed from Kahuilla
Construction over to Southern :Hills Development: Inc.. Thank you for your,help
in this matter and if you have any further questions, .please do not hesitate to
contact me.
The Summit at PGA West
1 81-0.10 Shinnecock Hills. Permit # 0402-016
.2 81-020 Shinnecock Hills Permit # 0402-017'
.3 81-030 Shinnecock Hills Permit # 0402-018
4 81-040 Shinne k coc H;II
5
i s
81-050 Shinnecock Hills
Permit #f 0402-019
Permit # 0402-020 _ -
6
81-060 Shinnecock Hills
Permit # 0402-021
7
81-070 Shinnecock Hills
Permit# 0402-022 '
35.
57-870 Troon Way
Permit #0312-01'1
.36
57-900 Troon Way
Permit #0312-012
37
57-930 Troon Way
Permit #0312-013
. 38
57-960 Troon Way..
Permit #0312-014
39 ' S7=990=TroonNa .
Permit:#031-2=415 ,
The Tradition
113
53-900 Del Gato
Permit #.031071.84
The Enclave
7'
49-045,Calle Flora
Permit # 0306-481
81-070 Chantidcer. Drive * La Quints, CA 92253 *;700-771-3497 " 760-777-8789 fax `
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CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS PERMIT NUMBER OWNER WFI/9Koriz PARr,h5rgS I LI_G BUILDER AAgd,ZI-A
This form shall be Hosted on the Job with the BuildingInsDection Card at all times in a �ti„spit [)fare. Only persons appearing on this list or their employees are authorized to work
on thisjob. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File' is not an acceptable response.
r.n,rd r rroa..:i:--.: . . _ .
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woricers Gom ensation Insurance
City Business
License
'.
s>>„ s:'• •
Company Name
ClassificationLicense
(e.g. A. B, CBI
Number
' (xxxxxx)
Exp. Date
(xxlxxlxx)
Carrier Name
(e.g. State Fund, CalCompl
Policy Number
(Format Varies)
Exp. Date
License Number
Exp. Date
(xx/xx/xxl
(xxxxl
(xx/xx/xx)
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+" 78-1"94 ELENBROOK CT
PALM DESERT, CA 9221 1
OFFICE 760.772.7192
SPECIAL INSPECTION WEEKLY REPORT FAX 760.772.7193
PAGER 760.776.3338
TYPE OF INSPECTION PERFORMED
DATE
SHOP WELDING
19 -Jan -04
PHYSICAL ADDRESS
PERMIT NUMBER
C-57=
STRUCTURAL. STEEL SHOP WELDING FABRICATION REPORT
Start Date: • i°`� Finish Date:
Fabricated at (K M. 5��1►�-� Job Name: l/UN16 b0iT 3`� � �®, �
FABRICATORS
PIECE #t
ASTM #
1k 1500
SIZE
10 YL
SINGLE
PASS
WELDING
MULTIPLE
PASS
WELDING
COMPLETE
JOINT
PENATRATION
WELDING
NON
DESTRUCTIVE
TESTING
DATE
REMARKS
1BLtdff', 5T-q0S
Ngo
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10 S, i<`/q
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Net,
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• All materials conform to approved plans, specifications, AISC, and AWS Dl -1 unless noted.
0 ACC in single pass, multi pass, or CJP columns represents acceptable welding and no corrective work required.