9608-043 (SFD)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 # Class Exp. Date
59797 P 7/31191;
Date 1`'Sigl turerof 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 withlicensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). :.•
() I am exempt under Section B&P.0 'for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
y '
I hereby affirm under penalty of'perjury one,'of Rhe 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 Issu�e�d:,M°yt,Xlkers' compensation insurance ca'merv%l ylno. are:
Carver 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 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 shall forthwith comply -With those•provisions. tf
Date: Applicant—
Warning:
pplicant Warning: Failure to secure Workers"comp sation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition:to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf'this application is made & each person at
whose request and for whose benefit work is performed under orpursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes -null and void,if
work is not commenced within 180 days from date of issuance 'of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, -and State laws relating to the building
construction, and hereby'authoriie representatives of this City to enter upon
the above mentioned property for inspection purposes.
Signature`(Owner/Agent) --y`' Date
PERMIT # CONTROL #
BUILDING PERMIT AD-I►�
36.60'
DATE 6— VALUATION �241,8►1),a0 LOT!' S TRZ-t341-1 '
JOBRSITE
ADDRESS
ESS
Al 5
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KS4 x A:ND
W �1 X3(11' ► Li£,'VIJ. ' .
�1 zticCi CC Lglf`.1"Pt.Y C..L UA :iiR, € 201
LA (WWA CA ' 9225:3
lilEkMLJDA, DUNES CA. 92201
(E,19)%44098
(61. ),A45-7755 CRLP 1969
USE OF PERMIT
;tl�lijl..1�'.iAA�I.�;IiS' .t.1W �st.l..ttti$t.i
• .
fan) uC 1,0T 5'
!
i.�tJltt"lfili'! 1']17 A64.00 'if?
C:iiP►AA4rF`1b;:AR-,P0, T 6175 -Ott SF
SjM'q�,11MX11,19 COST -OF C•O1'vSTRCJi.:`B.ION
Z41,bt 0.00
SIV 'CtdJ.IG1'ti3A3't iSf I1)1TfjtfCt> I# A{3@t1 S1,436.50
1'�. Al'i S;`1•f1a�'f: ,E�'�1� ! C�:i-t?t)(}�'139y33.� . �
.$85.50
ir`LUC'1"R K. Af, 01% 51'7.1.52
�'t.;1?lW31t�Bfr? FEB..101.90.419-000 - t7 :75
':i't't:.NICg>►r,�IrtjdE:r'-tfi!
C It"<1W N(1(; {x l .-M) .4213-W
twat ttA.S'IY,Rocti*F.Fvo," i2-4.5• WI) -4,01-;342 $5,331.57
11T!'C it�3!''1�31stf" Wf.fSC`23`, f3P4i) '7(3:E.(i(3C1...25:5•(3tlfi :63:54,511
S"i'FtCTC fa kND PLAN CHECK
$8,22:1,69
.l'€tD:-,1�r11i).t�f�f
$0.,00
TAl,-PE10117T aH 91CS WfEi NOW
SEP 0 3 1996
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
w
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 IA12 f,
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall doe
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVA S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground P[bg. Test
Final
Gas Piping
PLUMBING APPR VALS
.01
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
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
Utility Notice (Perm) - I I V_
COMMENTS:
I
78-495 CALLE TAMPICO - LA OUINTA, CALIFORNIA 92253 - :(760) 777-7000
OF �� FAX .(760);,777-7101-
TDD
(760);777-7101TDD (760) 777-1227
November" 18, 1998
RIVERSIDE COUNTY ASSESSOR'S OFFICE
3255 East Tahquitz Canyon Way, Suite 114
Palm Springs, CA 92262-6962;
To Whom It. May Concern:
Please be advised of an address change for the following structure. The structure
formerly addressed as (55=4'59 -Southern Hills; APN #769-820-016, Lot 5, Tract 28341-
1, the construction of which building permit #9608-043 & #9708=053 were issued, will.
now be addressed as 55=495 Southern Hills!
Please note this;change; and feel -free 'to contact me if.1 may be of further assistance.
Thank you.
Sincerely,
Greg Butler
Counter'Technician
BUILDING & SAFETY DEPARTMENT
MAILING ADDRESS- P.O. BOX 1504 _ LA" GIUINTA, CALIFORNIA 92253
r ifi� ate. of 0.ccupancy,Ce t c
City of LaQuin,ta
Building. - and Safety Department of
7
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-#Z SOUTHERN HILLS
Use Classification: SINGLE FAMILY. DWELLING . Bldg. Permit No.: 9608-043
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: R-3
Owner of Building:• KSL LAND II Address: 56-140 PGA BLVD
City: LA QUINTA, CA:, 92253
By: DANIEL P. CRAWFORD JR.
�^ Date: '7/2/97
` Building Official `
POST IN A CONSPICUOUS PLACE