9605-139 (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 # Lic. Class Exp. Date
ji)'; " r 5 li 7 i f.11(_+ti
Datef F' `r A Signature of Contractor /-
o
�l
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 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
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 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 WAIS, FUND Policy No. 4, -
4060371
(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„ofYSection 3700 of the Labor
Code, I shall forthwith comply with those provisions'
Date: Applicant
Warning: Failure to secure Workers' Compensationrcoverage 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 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
the above-mentioned property for inspectidn•�purposes.
Signature (Owner/Agent) r I bateAll /p”
BUILDING PERMIT
DATE VALUATION S241,839. 29 LOT
IOWNER
Pi Jti.RLt1F.rA.1 rN
y 4•f ( {{ ►(Pl Tf
ki-140 PPA. € IND.
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its 19)5,64- ORR
I USE OF PERMIT
PERMIT # CONTROL #
35203 TRAGI;1,4) IsI11
APN
761-4764124
CONTRACTOR / DESIGN�E��Rrr/ ENGINEER ^ //��
KANC1110 l.i�[�iL)�ii\.1'aNO
79687 CalJNi° Y C:LLU4 UK #201
Can. 'W12S3 BERMJi)A.DUNIRS CA 02201
(60)345,7755 CBMI 190
`11714F 1:101'1'AOE COL-i.FariaN AT PPA. WETt'
WAN 2-A,
CLI S `GNI C(YNSTRLIC` JON
PGtRC-1-1/f JA! 1'((,-'I
GAFUkGIJCAk3'C`1i7T
26 C0HP0RAi'KPA.tLK
2,87100 SF
3.1,00 3F
677.09 SP
RY11MAL ED COST OF CONSTRUCTION
241,939.20
C�ONSIRUCTIQNFIT
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f),1315 0.
PLAN C_.' C.'K .Fr:,):
t01-000.139-318
Won"
MECHANICAL V011
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225-000-443.341
E3TP1lC`110N AND PLAN CHtCK
LESS VRE-11:A D FEES $0.1111
D Ju92 6 1996 y p p t 9�r
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RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
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. 4
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVA11S
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 If
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
n
Certificate -of Occupancy
City of La Quinta-
Buflding
and Safety Department
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:
57-667 INTERLACHEN
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction: VN
Owner of Building: KSL LAND II Address:
-- City:
I � - By:
Date:
Building Official
POST IN A CONSPICUOUS PLACE
Bldg. Permit No.: 9605-139
Land Use Zone: R-3
56-140 PGA BLVD
LA QUINTA, CA., 92253
DANIEL P. CRAWFORD JR.
6/6/97