9512-120 (SFD)LICENSED CONTRACTOR DECLARATION
I.hereby atfirm that I am licensed under provisions of Chapter 9 (commencing with
r LU Nction 7000) of Division 3 of the Business and Professionals Code, and my
o Cy �`a ^ License is in full force and effect.
r WW License #_ Uc �Cla;0 8 Exp. Date I/ VV6
rnZ r Date Signature of Contractor
0 o� OWNER -BUILDER DECLARATION
J U I hereby affirm that I am exempt from the Contractor's License Law for the
III
CL following reason:
U) () I, 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
C0 Date Signature of Owner
N
0 rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
u-)0 cc compensation, as'provided •for by Section 3700 of the Labor Code, for the
X W W performance of the work for which this permit is issued.
0 J J (tif I have and will maintain workers' compensation insurance, as required by
m Q U Secllon 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:
d
3 rn Carrier Policy No.
Z (This section need not be completed if the permit valuationis for $100.00 or less).
co () I cdVffyA titriAT �e performance of the work for whibMis permit is issued,
O 1 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
e 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
1� construction, and hereby authorize representatives of this City to enter upon the
• , above-mentioned property for inspection ,p/u�rposeess.,�
Signature (Owner/Agent)IJ4 Z�� ( Data W
ALCi
BUILDING, PERMIT
PERMITi
DATE
VALUATION 8345,220 -
LOT 1.2
TRACT 28118 ;
JOB SITE ADDRESS
APN
81116,299 [WRMI'i'Esa E
761-4-74-4W5
OWNER
CONTRACTOR At
RANCHO CAPISTR.ANO DEVELOP
KSL. LAND 1.1
'79687 COU'I`ITR.y CLUB DP.. €:20
56-140 PGA BLVD.
BER IUDADUNES CA 92201
LAQWWA CA 922M
161%_14'5-7755 t CFkT,# 1469
DESIGNER/ENGINEER
R H G ARC1MITCTS
26 CORPORATF? PARK.
USE OF PERMI .,
INGLE PAMiLy I:AVELI NG
PGA W -M - THE h Amt rOtS Ct71d.1; MON PHASE T
PLAN 1-.811
FEE DESCRIPTION
FEES
CUSTOM CONT I MCIVION 4,127.00 .L>E:
P12.C1 PATIO 580.00 Sr
GARAGMARPORT 8170) SI'
ESTIMATED COST OF CONSTRUCTION
345,:220,50
�
PERMITFEE SUMMARY
P1,,ANC1IECY, VIM 101-000-439-31.8 51,21:7-43•
_
CONSTRUCTIONM 101-000-418-000 $1,500.50
A41 i:HANICAL FEE 1a1-f)00-421-ftUO $111.00
_ _ �
hLECTRICAL FES 101 000-420-000 $237.29
"PLUMBING,
Q M
cn
FEE 101-000-419-000 32343.01)
SmNGmoTio*., TSI:-Rtsm 100-000-241-000 534.5.3
60
GRADING rE:13 101-000-423-000 $20.00
'�.( CQ
IN Rt1STRUCT1JM FEET 22.9-000.443-342 $6,tM.00
l cJ
PREC, t SH PLAN 101-000-441-34.5 $25.00
11
AR'i IN VV13L iC PLACES - R1331r, 701-000-255-000 $613.05
SUE -TOTAL CONS"]'R, MION AND PLAN CHECK
$9,983.79
LESS PRE -RAID FEES
� , $0.00
TOTAL PERMIT FEES .DUE NOW
�5�,9SS.7ti
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD...
1".'OPERATION
--17NSPECTQR,.
DATE
OPERATION,
DATE
INSPECTOR_j
BUILDING APPROVALS
MECHANICAL H.ANICAL APPROVALS
Set Backs =2 --6'- 9K
Underground Ducts
Forms & Footings
Ducts
Ducts
Slab Grade �4 4;?C: 'AV kT,-
Return Air
Steel —Z. kco
0 us
Combustion Air
Roof Deck
Fans
g
O.K. to Wrap
U
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T-0.
Fans & Contr641
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/7
a 4z
Final
Final
BLOCKWALL APPROVALS I
POOLS - SPAS
Steel
Set Backs j
Electric Bond,
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas TestElectric Final
Lines.0&zzo�r
Heater Final
—Waste
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral A
Pool Cover
Sewer Connection /44 91,6
Encapsulation
Gas Piping
Gas Test
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: -
Certificate of Occupancy
City of La Quinta
Buflding.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:
Occupancy Group:
SINGLE FAMILY DWELLING
R-3 Type of Construction
Owner of Building: KSL LAND 11
Building Official
80-298 HERMITAGE
Bldg. Permit No.: 9512-120
VN Land Use Zone: R-3
Address: 56-140 PGA BLVD
City
By
LA QUINTA, CA., 92253
DANIEL P. CRAWFORD JR
Date: 2/14/96
POST IN A CONSPICUOUS PLACE