9603-130 (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
11
Date Signature of 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 with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I sm ?YPmrt ilnrlor Sortion , t3Y:P.C, for thio roaoon
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 !kVNTtioC"()tvl3 Policy No. ::2y-%6ttf*3114
(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 thwworkers' compensatiiora provisions of Section»3700 of the Labor
Code, I.sh I forthwith comply with those provisions.
Date: Applicants' �!C"',Ze-1 - t-----�^
Warning: F� ailure 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 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 prope, //fo Ir -for inspection
purrpposes.
Signature (Owner/Agenti/ / i%Gt Date���
�r
BUILDING PERMIT PERMITk CONTROL��#j}
��{��� 9
DATE VALUATION LOT TRA
AI'v) P11 if
JOB SITE
ADDRESS 54.495 WINGED FWT
APN
769-4501 0d!
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KSL LAND It
RAPdf.'140 CA SI'i2A>+JC)'I)E%r;f,.C)PAIE
'50-F40 PGA BLVD.
196Wt COUNTELY CLUB DR. #2101
t.A Qf TINTA ("A 9125:1
BERNU Tt,)n MINES CFA 92201
(619)W•- M?
vl3 O
4t t%1 iC1��kii t�Fwir�F.
USE OF PERMIT
�+Jlvi Ft,� t=.(1itt14,1 ')>1��%1�1.),�lVt
t7<.��? !Mti')'t°ttE;t.E. <�tif►°I�t
fK.V)Nki, CA 9XIT i
►AU'.Xfl&ACi-iJ,LE "ftQN Xrt ITAwlF_ t
Pf AN ', -A
C 011 `i°c)1vt
t�C?li�t"fd/Pr17,'tCi :�r`?.fft) 5t+
OAR I1tiWC'Aibt"C>XT 02 00 8F
ESTIMATED C'US f OF CONSTRU", .ION
200,201.0
IttvS°111V"1'I(>I� 1`r� �V!"4Vil��Jt1'i/Vi! J�dtl�
1014MAM-00 S98,5')
t ter `i'tttc cii..F`�.�, tbl-4titi� ��f�.p011 S b 5 �_4F
.
P: It MyMNO FIT. 1.1)1 000.414 100
STOW -l' 410T FEE -• WS11) 101-000-241-000 Sihl°(12
6RADIN01 f -W." 10.1-000-423aCW S20.0)
[NFRA#34'R0_..'i`i.TRF! FEF $4.444.tv,9
SIiT)-"ti3'iAL CONST1.1 `t71ON A.ND PLAN C:1iL°C'
yEi.��t �t
LESS RRF-PAW FEES
r--.
I , ,A1, i'VRNlrf i EISS DTT , NO3'1"Ir
Sf+,"UM
JUL 2 6 1996
fl13 �
RECEIPT
DATE"
BY
DATE FINALED
INSPECTOR
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
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P1.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath r
Final
Final
POOLS -SPAS
BLOCKWALL AP I PROVA4S
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP RO 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
Pool Cover
Sewer Connection 17 f X f
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 zwl:j =ell
tAlity Notice (Perm)
Certificate of Occupancy
City of La Quinta
Building 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:
Use Classification: SINGLE FAMILY DWELLING
54-495 WINGED FOOT
Bldg. Permit No.
Occupancy Group: . R-3 Type of Construction: . VN Land Use Zone
Owner of Building: RANCHO CAPISTRANO
DEVELOPMENT
i
Building Official
9605-130
R-3
Address: 79-687 COUNTRY CLUB DR #201
City: BERMUDA DUNES, CA., 92201
By: DANIEL P. CRAWFORD JR
Date: 2/19/97
UOUS PLACE