9602-084 (SFD)1. LICENSED CONTRACTOR DECLARATION
I ;Pereby affirm that. I amlicensed 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. SM5075 1'S /'' 131i90 F
License # % Lic. Classes /ExP Datei
Date :{/ Signature ofContractol' YEW//
�r ,
OWNER -BUILDER DECLARATION
I hereby affirm 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).
O 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 ofOwner
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 370pof the Labor Code, for the
performance of the work forrwhich 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 Policy No.
(This sectioiifdiWc n -6V66 completed if the permit valuatJdKNs-foF($*00?GO 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 We workers' compensation provisions• of Section 3700 of the Labor
Code, I sh Ifo ith comply 04those'provlsions.
Date: : ,1 Applicant
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'tthis application agrees to, & shall, indemnify
& hold harmless the City of Indian-Wellsrits 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 C' .to enter upon the
above-mentioned property for insp tion pur oses.
a
Signature (Owner/Ag � ", / , - .. � 2('d Date
ALCM
•
IL
DING PERMIT
PERMIT,�M f� 84
DATE f s TO
VALUATION
LOT TRACT
JOB SITE ADDRESS' 54-0.5WINC .B) FiB
APN 70 -450-045
S
OWNER
CONTRACTOR
RANCHO CAP1STRANO D VL
K S L -LAND 11, .
'y'i787 tr"(?U NTP. ' CLUB 'DR #2
56-140 PGA BLVD.'_,-
! 131:11_i19UiDA WNES Cry !220.1
-LA QUINTA, CA 92253
(1519)345-7755 CBL# •1989'
DESIGNER/ENGINEER
CYP sN"I`lFIMT1fJNAL
1799:2 i�'.II.TCi]. y1�..I, Jt'� WTI
( 619) 564-11088. j
. , .c�'.!` d .IV T{. I-,i7l7VW!' L71;i115+3."` .�.i
USE OF PE_Ol v
11WIN1 .C`A 7 i 41660,4910
11M13YDERRCi.W C110N A: :FK1A V'E811't'.HA,%13 1 .
PLAN 2 -
FEE DESCRIPTION
FEE'S
CUS'T'OM C(aNS RUC -110N 2,379.00 W.'
13r+RC1IfPATI'4 202.00 SF
GAIL GEICA tPGiRI 622,G4 SI'
EsT i1LIA'i'ED COST OF C"CtNfi'i'RUCTION
2",201.90
PERMIT FEE SUMMARY
PL AN CHECK Ff } '! -�d0-X39>31.i3 $8166 24
CID, NSTARUC`1'ION FEE. 101-409-41 $993.00 .
W_-,QNAN1CAL ill: 101-000-421.-000 $98.50
ELHEC-1RICAL FFE 101-000-420-000
:PLIAX iBING 1h'B 101-009-419-000.
Sa"ONGIMOTION F M - R2 SID 101-00.0=241-1000 $20.02
GILADINO FRE 101, 00(? -423-000 $:20.00
1NFRAS1'R1LICT1lkiE,'FFE 225-000.443-342 $4,444.09
Al2T 11v'PUBLIC PLACES �.RESID 701-000-2.55-090 $250.510
SUB-TWAL c ONTSTRUCTION� ANi3 PLAN CHECK
4 LESS PRE-PA.ID FEES
D
$6,968.81
so.*00
FEB WFAL PERMI ' FEt8 DUEN07W
2,1 ;996
�jIY
RECEIPT
DATE
BV
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.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath / f
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL AP ROV S
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
te of OccupancyIwCet'tifica'
C
ity of La QuWanta,.
Building and Safety Department MOF�
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: 54-635 WINGED FOOT
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9602-084
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: R-3
Owner of Building: KSL LAND II
Building Official
Address: � 56-140 PGA BLVD
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR..'
Date: 5/28/97
POST IN A CONSPICUOUS PLACE