9608-052 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurpithat 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 # Y Lic. Class Exp. Dates
Date Signature of,Contractor,
OWNER -BUILDER DECLA ATION"
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 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
.w
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 fob which this permit is issued.
(.) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the La or Code, for the performance of the work,for which this
tii'UAJ ,1 h, d,1 J _y feN 171
permit is'Issu ct. My orkers' compensation insurance ca er policy 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 manner s6,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,44h those,provisi6ns.
Date: Applicant
Warning: Failure to secure WorkersCo pensation 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, 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 statethat 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 property for``inspection„purposes.
signature (Owner/Agent)rr
UILDINGPERMIT PERMIT# CONTROL#
DATE S . j VALUATION .SZ -866384.40. LOT', '14 - TRACT -341-1
JOB SITE a f3�a,J111�T.� 2�S T MIAs APN 10-•91"H.6
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
.ni- i 0100 i i ii isj�fi Id, "r9lif3fi �.,17ir�i'i fZY 92,01
L A (,)jJIN'1"A, CA. 92253 13E't MUDA DUN1,S. CA 93201.
f(i.IiA5i :1 -it 1619)3454755 011114 196$9
USE OF PERMIT
SIN -4,E
3A_JL,0T 14
PO RCI-VPATI() 31910 SF
c.3AfEAt IUCAR:1•'ORT 583.00 %'
.�,5'�,Ta1!1.�t.)1 -1) C09T OF CO NST'iRU MINI
yy..
tIONSe'1+R>,:rC'tIONFEE
t(I-011 0418 -OW
$1,%94.0x0 :
fl KIN, C"Ecy P
.101- -439-t3�18
$1.056.9"
i�itAi:t ltulL>yktt.l'153
1001-0 i2t Q+3v
5.1240
HL'EC'MICtAL IEEE
101-0010-420.000
$1€39.60
Pi U1b113.INC3 F17..E,.
101.40-419-000
$213.25
STONO XIOT'tOIWFUE w 1�.^MD
10I1 M-241-000
$28.64
.101- O423 -WO
$20.030
ttJO� l L E FEE
'22_5.000-�3 6-342 ..
$x,060,0
ART IN PUSL(0, KA:JM - RESIC 701-00- 56ti 00 0
$40,96
iuLU-r:st it+ S I RUC -f TON A.ND T'i.,_AN CHECK
® t. ;ti k" 'E-PAt13: EEki $0.00
t lu'..-PE1t41T' RS ,041E NOW $9„39.2,37
SEP 0.3 1996
RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 4- g4g
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing 6
Compressor
Insulation 9
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 7j
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final I
Gas Piping
PLUMBING APP O ALS
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 ZPool
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Ce'rtificate of Occuplancy 0j
City - La- uinta
Building and.Safety D epartment -
CFM OF
> ' 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. constructionor use. For the following:
BUILDING ADDRESS- 55-599 SOUTHERN HILLS-'
Use Classification: SINGLE FAMILY -DWELLING -Bldg. Permit No.:. 9608-052
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
f By: DANIEL P. CRAWFORD JR.
.'Date: . 5/2/97
Building Official