9608-050 (SFD)LICENSED CONTRACTOR DECLARATION
I r gceby affirm under penalty of .perjurythat 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 y Exp. Date
3!�!91J {.'% t � •'lir aJ�1i t
Date Signature,of Contractor Y p --� ' 4
'OWNER --BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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 .thet project (Sec. 7044, Business &Professionals
Code).
() I am exempt under Section• B&P.C. for this reason .
Date 'Signatureof 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. '
( ) I have and will maintain workers' compensation insurance, as required. by
Section 37,70 • f tlje.L.abor Code, for the performance of the work ,for ,which this
5'1 A� f INA 1 �4_ i�li .,1
permit is'IssuedE My workers' compensation insurance. crner & poilcy. no. are:
Carrier Policy No. '
(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 manne sr o as to become subject to the
workers' compensation laws of California, and agree that if 1":should"become
subject to the workers' compensation provisions of Secti n 3700 he Labor
Code, I shall forthwith comply4ith those provisions. C r;
Date: Applicant 2::-�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminalpenalties 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 4orth 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,thisCity to enter upon
the above-mentioned property for inspection/purposes:
Signature (Owner/Agent)
BUILDING PERMIT
PERMIT# CONTROL#
<�6a��.:a�U 3 8 6 7
DATE � ice' VALUATION ��4PJ.91� 74) LOT
is TFACT, R%•1'
JOB SITE T..x59isZ ��01 itJ±1.91{! {.Yf.1r{n)
APN %i►'�E-{.i{j1.{f,
ADDRESS
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER I
i_il,3,'d .
3�rtib,,t.�. tiN 'lid' L.1 ti -I)R 6f2tZ3.
1,A 0,111;1* I -A CA 9253
8EI.IttvILID A D[:7N1 S, CA .02201
USE OF PERMIT
W M1.YNA T 1() } 102.00 SY
kiR:li r ?ii1CA1 +a R7 661.00 8F.
Ij ERMfT VEE WAIMAR.Y
�+?'t�S!`.621��'117S,J�'f:3E .if-).9-Ut)C>-�IIt3-t3tl{i
�1,07�.3U
PLAN C1 CK 636 101-000,439418
1874.53
WCUM tCIAL "'FE 10)1-000m4 111111
579.00
3;?{.l1C:rttUC'AI, Fart 101-0004104)t9()
516•.63
t'Z.f.1t�i{3f 1�IC1- 101. 000 -419 -OW
$aa1s: 5
a f 4:NTO N90ft01�•: FiU% m `lUMIL) 1011-p(�-2414"
S?^� 3�
"►i3e PM_lU x}t)()�23-OtJO
$20:OU
INMAS`C121JG'x'i!1'iksFIRk, 21-5-00-.4#3--..342
S4.f�S,05
ART to KJ13L,1C .Pf,ACES* - REM 7191 AX11 1,255• =
S309,0
SUI :�"1'E3 rlui coteaf`RuC`I'kC N AND PLANT C`.HC+1 K
$7,677.85
LESS 14F -PAID FVES
_ i y�pq .r y� ytl4 `_y/�t�r
'
$0.00
9T'kt� . �r 6 .4:,f.i NI �: Y. . ,k'_.i'n7 DU E i O �'7
SEt 0.3 1:79'.
BV ;.
RECEIPT
DATE
BY
DATE FINALED'
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
09
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
op
F.A.U.
Framing
Zjk7
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
oeb
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Final
Gas Piping
PLUMBING APPRVALS
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
Encapsulation
Gas Piping
Gas Test
s
Appliances
Final
COMMENTS:
'
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
Utility Notice (Perm)
ffCertificate of Occupancy
City of La Q.uinta �
Buffding.'and,Safety Department �°EMoFTM
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 55-569 SOUTHERN HILLS
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9608-050
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: R-3
Owner of Building: KSL LAND II
Building Official
Address: 56-140 PGA BLVD
City: LA QUINTA, .CA., 92253
By: DANIEL P. CRAWFORD JR.
Date: 5/16/97
POST IN A CONSPICUOUS PLACE