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LICENSED CONTRACTOR DECLARATION -
I hereby affirm 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. 597975 B I/ U96
License # Lic. Class Exp. Date
Date Signatureof Contractor ", h,`r,
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Low 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 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
Sedition 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 secV0nbt,�6.ed notib'.e completed if the permit valuatiol'%;W14000.00 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 inspecttio[n,�puurppos^ess:.
Signature (Owner/Agent) Data
ALC
BUILDING PERMIT
�:�sx�il7
PERM'T`'
DATE- r
VALUATION `s'��+ K ' "�
LOT YTRACT
JOB SITE ADDRESS 80-250 HERMITAGE
APN 761-470-039
OWNER
CONTRACTOR
RANCHO CAP121MRANO DEVELOP
KSL LAND 11
79687 COUNTRY CLUB DR #20
56-140 PGA BLVD.
BER MMA OU14ES CA 92201
LA Q INTA CA 92253
(619)34-5-7755 CB11# 1 *9
DESIGNER/ENGINEER
B B G Al 0711TECTS
26 CORPORATE PARK
USE OF PERM15 L.A, FAMILY J VYy' L t Vt:i
(RVR -4R CA 92714
PGA WEST - A".R MAS WkS COLL"17t TION PRASL I
PLAN 1-A
FEE DESCRIPTION
FEES
C;US'FOM CONSTIRCC AON 4,127.00 Lk
PORCH/.PATIO 580.00 SIF
GARAGWCARPORT 817:00 SF
ESTIMAT1✓D COST OF CONSTRUCTION
345,220.50
PERMY-1' FEC SUMMARY
'PLAN CHECK FFY_ 101-000-439-31.13 $1,217.43
CONSTRUC'11ON FEE 101.•-000-415-000 $1,500.50
;MECHANICAL ME 101-000-421-000 $111.00
ELEC'MCAL FFE 101-000-420-000 $237.29
PLUMBING ]".IsF 101-000-419000 $231,.00
Ln
C
STONG MOTION F= - RESIIa 100-000-241-000 $34,52
rn
GRADING FEE, 101-000-423-000 $20.+30
00
I14117-.RAS'1'RUCTURE FEE 625-000.493-342 $6,000.00
( CIz
PRECISE ALAN 101-000-441-345 $2.5.00
�l c-)
RT
AIN PUBLIC PLACES - RFSIC 701-000-255-000 $613.05
�
SUB- TOTAL CONSTRUCTION AND .PLAN C.14ECK
$9,988,79
LESS PRE -PAID PEES
$0.00
TMAL PERMIT FEES DUE NOW
$9,988.79
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
C
F OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs - g - KC 7
Forms & Footings
,Slab Grade ,L
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wail Insulation
Party Wail Firewall
Exterior Lath !
Drywall - Int. Lath Vj
Final
BLOCKWALL APkOVALS
Set Backs
Footings
Bond Beam
Final
PLUMBING APPROVALS
Waste Lines — -
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
Utility Notice (Gas)
ELECTRICALP ROYALS
S
Temp. Power Pole
Underground Conduit
Rough Wiring t
Low Voltage Wiring
Fixtures
Main Service i
Sub Panels
Exterior Receptacles -
G.F.I.
Smoke Detectors
Temp. Use of Power °
Final
Utility Notice (Perm) I ;
OPERATION DATE INSPECTOR'
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines _
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
OX for Finish Plaster
Pool Cover
COMMENTS:
a
Certificate of Occupancy
City of'La Quints
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-3
Owner of Building: KSL LAND II
80-250 HERMITAGE
Bldg. Permit No.: 9512-117
Type of Construction: VN Land Use Zone: RL
Building Official
Address: 56-140 PGA BLVD.
City: LA O.UINTA, CA. 92253
By: B. PELLETIER
Date: 12-4-96
POST IN A CONSPICUOUS PLACE