9701-106 (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
IN -W Professionals Code, and my License is in full force and effect.
O Z) ch License # Lic. Class 1 Exp. Date
r W r 73 11" 1 `.
6 Z � /Dat/� Signature of Contractor ^ "!r
T O ,.�
U rn OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~
CL
License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for. this reason
LO
N Date Signature of Owner
ON
C)
d Q WORKER'S COMPENSATION DECLARATION
Z I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
. W compensation, as provided for by Section 3700 of the Labor Code, for the
2i" � Q pert rmance of the work for which this permit is issued.
b Q UI have and will maintain workers' compensation insurance, as required by
U Q S ct on 3700 of the Labor Code, for the performance of the work for which this
i I— - ermit is issued. My workers' compensation insurance carrier &. policy no. are:
? Z Carrier77ryry���� y�tC (p WPolicy No.
O LIJ.R. 01 INS. W. ' 'PC 4333%`105 .
Q (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•Sectien 3700 of the Labor
3 ✓ Code, I shall forthwith comply with those prov'sions. Date Applicant'"/'�•.:-
y
Warning: Failure to secure Workers' Compensation coverage is unlawjul and
shall subject an employer to criminal penalties and civil fines up to $10',000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton, agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby -authorize representatives of this City to enter upon
the property for inspection purposes. ,.�
,/Signature (Owner/Agent) /
BUILDING PERMIT PERM CONTROL#
1
'"
DATE . VALUATION LOT ""r TRACT
114
JOB SITE ysy+�-
ADDRESS° ��if lt!'i�.C��tl
APN
/i7-�►�'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
K'S 1, LAN D 111..
KSLOFlT�,0�'13�•�x!"�`C'1'�n .
54o 146 PGA BLVD.
_ail40 'PGA BLVD
LACAANTA C'A. 922 ►3
LA QVINTA C.A. 92253
tsm
USE OF PERMIT
FOA NiA;3'tERS,
f
dr J,,sru1Y1 LS..�.1VS'1`i�.irt'7`.iQ6� 4,250.00 !,IF..
1yGT1�I:U1'�A'.flf:5
l3AFdAxr�C'.A:i1.2:r '713.00 SF
:�x3��mum Gos` '`.fir CONwrRuCTION
MARY
1'Ri#Mr1" FEE SUMMARY
'PLAN CHECK rfl
CON,S'F A !"!ON0_31,8 lC114 000-d!8-i,?M 11,53$.50
N
1111 C:-Y6''QN1CA1. F03 101-00(),-.42 I -00a $143.50
'
ELVCNIC AL 088 $2139..51.
}?;.d�1t4i3t7ilf f 1^l31 1.0'!-Uf' -419-000 a2"RA.O(i
STONO N10'f"f0N 1;13T.-AES111 lC11-000'24 e �(fi�!} 35.SfS
cn
C. -TZ .A 1: ON(', PEG 1014 OU -•423-000 �7t7.tJ
rn .
tM1 f2�11'ftUti:'Ltf11:f 1.�> '25 t]GU-x=23d"r!04.ixi�
® CID
Yl ECISP'PLAxd
M17 i14►_'•i1COAC pLe~03.S - R131T` '703 wm.�`�
cz
.)
fAJB-'!Xn AL COiNST UC"U.ON "10 PIAN 011';r-;9"
X10 t�l,fifl
LESS Fl`>ES
$01.00
'rarm, PERMIT FCF.S DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
I
INSPECTION RECORD
t OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing AIMCompressor
Insulation5z"YZVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
G
Final
Final — —1?
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
�10'7
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test ,2 .S _ S'
Appliances
Final
Final. _
Utility Notice (Gas) g
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G:F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) ✓
COMMENTS:
c/�,
®FCS Qvi JON TANDY
8i%ot 13580 Condalia Ave.
Yucca Valley, CA 92284
SPECIAL ,s,ili�-l-,, (619) 365-5045
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY ❑ S NoP
❑ POST TENSIONED CONCRETE ❑ ASPHALT) OTHER ���)) �1'
❑ REINFORCED MASONRY ❑ FIRE PROOFING W i-diw
JOB LOCATION+$x z_ , ..
:38 ER n1:i..-lkc ez - cc -0 u: r nq-)
REPORT SEQUENCE NO.
TV PROF $ RUCTURE � 61 A- WCC
G 7
PERMIT N0,
DRE'.3-q^
/
DAV OF WEEK
MATERIAL DESCRIPTION
1�3� -500,
ARCHITECT
INS/7SPE TOR�
J T/4&1
HRS. CHARGED
E-Zir- ri L-7018
ENGINEER
ASSISTANTS
HRS.CHARGED
INSPECTION GENERAL CC SUB
DATE CONTRACTOR , J• . CONTRACTOR
08SEAUGd U)Gid, A1 C -O S. SEE
A4ach = F,46kld-ariodEAokZ-
E �
COPY SENT TO CLIEN l
CON UED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE 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.
t_ T3 _ q�REGIST 0 P4 't
DATE OFREPORTREGISTER NUMBER
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: SFD
Occupancy Group: R 1
Owner of Building: KSL LAND II
80-138 HERMITAGE
Bldg. Permit No.: 9701-106
Type of Construction: VN Land Use Zone: RL
Building Official
Address: 56-140 PGA BLVD.
City: LA QUINTA, CA 92253
By: . STEVE T RAXEL
Date: 2-25-98
POST IN A CONSPICUOUS PLACE