9512-114 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
ection 7000) of Division 3 of the Business and Professionals Code, and my
License is in full force and effect. a919i5 1i li liiti
License # Lic. Class Exp. Date
Date Signatureof Contractor
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).
( ) 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 Signatureof9wner
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 Policy No.
(This sectjgj7jneed1rtoie completed if the permit valuation js)ior1$i10g.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 Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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 this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 inspection,purposes.
Signature (Owner/Agent) Qom--' Data
ALc9
_BUILDING PERMIT
PERMIT 512_114
DATE 12122
VALUATION •J,791..LK .•
LOT tY TRACT+` f'
J08 SITE ADDRESS &t�-Z112 iiiiRMtTAGp,
APN 761-470-036"
OWNER
CONTRACTOR
RANCHO CAPIST/RAyy NO DE VE'LOP
ktn is
"7116.117 (110,11NI'M CI LIB DIR i«U '
_%4410 PGAL BLVD.
BERMUDA WAS CA 9220I
L.A. QU1NTA CA 92253
(619)345.7755 C8L# 1909
DESIGNERIENGINEER
BB G AR.C1`II WTS
26 CORPORATE PA1t1;
USE OF PERMItiiIVC,ic. 4 PAi4 IL 13W ELLING
.POA b &ST -'IRF,, MA.')I ~RS COLLE, PION
PLAN t -B
FEE DESCRIPTION
FEES
CUSTOM CO NS'i RUC'i'1UN 4,127AW LF
PORCH/PATIO 1800 :sly
GARAGEtCARPORT 817.00 SF
USTIMATED COST OF CONST RUC' ON
34E5,220.,
PLAN CNEC,R,FEF 101-000.439-31.8 $1,217.43
CONSTRUCTION r 3l 101-000-44000
NJEC iAMCALFE)✓ 101-000-421.-" S.1il.tNi
ELECTRICAL FEE 101-000420-000 ' $231.29
rn
PTAJN4BTNC, .FTE 10149111-419-W S2.'1().(W)
® rn
STONG MOTION MY,. . - RES173 100,-000-241-000 $34,52
GRADjNG FM 101-600423-000 120,00
C\1
1NFRAS'1RUCtVRF.F% F. 225 -OW -443-342 $6,000,00Cl�
v
PRECTISE !�LM4 101-000-X01-345 $25.00
�
AW2 r 1N PUBLIC PLACES - RESW 701-000-255.000 $613,05
SUB -TOTAL CONSTRRU 1 ON AND ALAN CHLCK
$9,9&''4,71
LESS PRE -:PAID .BEES
50.00
TOTAL PERMIT FEES 01,1ENOW
$9,939.79 '
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR
INSPECTION RECORD .
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -
Underground Ducts
Forms & Footings _lG g
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck 't It
Exhaust Fans
O.K. to Wrap l•
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
Drywall , Int. Lath
Final
Final
SLOCKWALL APPROV LS
POOLS - SPAS
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 41
Pool Cover
Sewer Connection Z 1
Encapsulation
Gas Piping
Gas Test
Eli kz2y =67
Appliances
Final
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)
COMMENTS:
<
A
Certificate-O'f 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: 80-202 HERMITAGE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9512-114
Occupancy Group:
R-3
Owner of Building: KSL LAND II
Type of Construction: VN
Building Official
Land Use Zone: R-3
Address: 56-140 PGA BLVD
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR.
Date: 6/25/97
POST IN A CONSPICUOUS PLACE