9701-109 (SFD)LICENSED CONTRACTOR DECLARATION
1, 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
Date Contractor) Signature of C cto r1li,,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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:
lhave 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 perrriit 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;
Cartier Policy.No.
AXICR INS. co, VlC F3:39 $05
(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
"'ode, I shall forthwith comply AKthose pro
visions.
Date: ""A A il 1417 Applicant -,eA-�X
7 4- r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up.to'$100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and.for whose benefit work is performed under or pursuant.to
any permit issued as a result of this applicator agrees to, & shall, indemi4ify
& hold harmless the City of La Quinta, its officers, agents and employee&
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180. days will subject permit to cancellation.
I certify that I have read this application and state that the above information is,
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
t, e above-mentioned- property fo-rinspection'06irposes.
-f
t,Zinn�ature* (Owner/Agent)J-I'X�L J� U I
PERMIT# CONTROL#
BUILDING PERMIT 48, 6 4%
DATE VALUATION -LOT' TRACT-
JOB SITEAPN
1ADDRESS, 4Z$Z S-1 G b Ufi. rZ N -it] J
OWNER
CONTRACTOR/DESIGNER/ENGINEER
KS L DEVELOPMENT CORP.
SQ40
56-140 AJA 131,W).
1.11 QWNTA CIA 0221"
LA g(AMA. CA 92753
(760)771-3(42 C1311.9 -
USE OF PERMIT
PGA Wt SY - RY-MA PLM 3k;
CUSTOM CONTSIMCITION 2,450.00 5F
243.00
OA_RAWCARPOWJ[' 527.00 SF
PLAN CHWK FEE 101-OW430-318 5821"
CONSTRIJCT ION FEE 101.000-4183-M S1,007M
NOKCHANICALFUS' 1.01. -000 -42] -OW
aW,T1UCAf;.V@_4*8 . .101:400A20-000 SA -D.14
PIXTYWRINO FERIS '101-000,419,000 V6715
9TR.ONO MOTION (11873). 101 -000 -?41-000.
I2ALYt 01:13 101r000-423-13(1(3 $20.00
AS -000-443-342 "K526.64
JWT IN KfE(LIC K-ACPS (".,S) 1101-000-255-000
1,1A
IKUCONSTRUCM,0NAND PLAN CHECK
Mr5-PAIr
LESS . FF16S
TOTA�11 PC H 11111' FE F.S.91 J C N OW
S7,071t.50
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
iS
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
/
F.A.U.
Framing
/
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
f
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
71
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 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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:°
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
�y x..„Y •irt _ S,.Ywrc y � i.y s. .. n,.vF��.+�":Pi.� � 3.
Y4
I
JON TANDY
3580 Condalia Ave.
Yucca Valley, CA 92284
(619).365-5045_
REGISTERED INSPECTOR'S WEEKLY REPORM
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE RUCT. STEEL ASSEMBLY ❑
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONRY 0 FIRE PROOFING
'OBt/ u�� � �` LA,�� ` �
REPORT SEQUENCE N0. ;
TVP OF STkUCTURE
PERMIT NO.
0 E
DAY OF WEEK
MATERIAL D SCRIPTIO, ^ _�
S'D
ARCHITECT '
NSPECTOR •
�ASSSSISTANTS
HRS. CHARGED
ENGINEER .
HRS. CHARGED
INSPECTION GENERAL I SUB
GATE - CONTRACTOR �_Q�� 1 �, _ CONTRACTOR �S•��.I.��
-U f C-Ot^4 N e C l c 0 c-•( tp (A T E7S 70
.es. s�x,L y
h
,
jIg–e ( N a1
r
COPY SENT TO.CLIENT V,
CONTINUED ON NEXT PAGE O. -
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE, INSPECTED. TO THE BEST OF MY
KNOWLEDGE ALL OPTHF. ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
• PLANS. SPECIFICATIONS, AND APPLICABLE SECTIONS OF” THE
GOVERNING BUILDING LAWS.
SIGN TURE OF REGISTI1,H3D INSPECTOR
1Q�� ;) �ZA`a
DATE F REPO REGISTER NUMBER
Certificate*: ofOdcypancyT
City of'LaQuinta s
_
Buildin' and Sa -et De artm nt - �� of
g Y 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 regulating building construction or use.,, For the following; - -
BUILDING ADDRESS- - 55-586. SOUTHERN HILLS
Use Classification: SINGLE FAMILY DWELLING, i Bldg. Permit. No.: 9701-109 -
Occupancy Group: R-3 Type. of. Construction: VN ' Land Use Zone: RL
Owner of Building: -KSL LAND II Address: , 56-140 PGA BLVD
r City: LA QUINTA, CA., 92253
'By: DANIEL P. CRAWFORD JR.
Date: 10/22/97
Building Official',
POST IN A CONSPICUOUS PLACE
L