9512-115 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
j� Section 7000) of Division 3 of the Business and Professionals Code, and my
C:)^ � co License is in full force and effect. 597975 13 11.1196
r-. W^ License # Lic. Class Exp. Date
ZDate Signatureof Contractor
p o> OWNER -BUILDER DECLARATION
J IU 1 hereby affirm that I am exempt from the Contractor's License Law for the
CL following reason:
co ( ) 1, as owner of,,the property, or my employees with wages as their sole
Z 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
0 Date Signature of Owner
N
OU rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
C)2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
� �<O cc compensation, as provided.'fdr by Section 37001of the Labor Code, for the
X W LL performance of the work for which this permit is issued.
p J J (} I have and will maintain workers' compensation insurance, as required by
C0 Q V ' Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
CL rn Carrier Policy No.
Z (This sectiy-pj606dA tie completed if the permit valuation, )fo►1$140.00 or less).
00
a ' () 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
fora 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
44
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.
fw
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) f_
Dae /,7/1 V 4t_
.
ALc9
___BUILDING PERMITPERMIT1,sn_ius
DATE g :7
VALUATION LOT f TRACT
JOB SITE ADDRESS $Q-�jl$ i R�4rTA
APN
761-474-017
OWNER
CONTRACTOR
RANCHO CA.P.IS R VNO DEVELOP
01. LAND 11
7<>: 47 CtAD1TU C!"U8 D ,':20
56-i 40 PGA BLVD.
BER&I'UliAD'uNES CA 02101
LA. QLWrA CA 92253
(619)345-7154 CTRL# 1969
DESIGNER/ENGINEER
B D 0 ARC:fIiTEC•TS
26 CORPO ATE PARK
USE OF PERMIT>.M1(jL ' A ' L.YL. 1 U•
TR . (' A gr 4
P )A WEST - THE IFOASTEIW COLLECTION ISNASFS ,I
PLAN 3-M.
' FEE DESCRIPTION
FEES
C;1 JTFU.M CO NS'.t'1CUG 71014 4.542.00 LF
POR.CH/PATIo 7,5.00 S1:
GARAGE/CARPORT 811.00 .ill+
0STiMATED :'OST OF CONSTRUCTION
379926.90
PEl MIT .i<' E SUMMARY
I.LAN CHECK EL 101-0,00-439-318 51,312,62
CONSTRUCTION FISC 101-000-418-000 $1,61.9.50
j
MECHANICAL FEE 101-000421-M $l3T.Oi►
I:dE;TRICALFM '101-000-420-000 $251.69
0-)
PLuluff3?.rlC.7 M 101.000-4119- G0 $230.(*
�
STONO MOT10N,'Fix.- RESID 100-0-00-241-000 $37.92
00
GRADING 101-000-423 000 50.00
C,3
WRA3't'RUG URF.• FES 225-000-443342 $6,000.00
4 � c
ART IN PIJALiC ,PL Af.T-,, -:ESLD 701.000-2.85-()00 $438.97
Ld
SLIB-717FAL, CONMUC110N AND PLAN CHECK
$10,306.80
LESS PRE -PAID FEES
$0.00
TOTAL PF RMIT FEM DUE NOW
510.30080
RECEIPT
DATE
BY
DATE RNALED
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
1
Exhaust Fans
O.K. to Wrap
_
i
F.A.U.
FramingCompressor
Insulation
2 F&_
Vents
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
POOLS - SPAS
BLOCKWALL
APPROVA 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
f.
Encapsulation
Gas Piping
-
Gas Test
Appliances
Final
COMMENTS:
I
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)
Certificate of Occupancy
City of La Quinta
Building and Safety Department �°OF
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
80-218 HERMITAGE
Bldg. Permit No.: 9512-115
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: 5/16/97
POST IN A CONSPICUOUS PLACE