9708-065 (SFD)1 LICENSED CONTRACTOR DECLARATION
Ar' I hereby affirm under penalty of perjury that I am licensed under provisions of
F- / Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
r 0i W Professionals Code, and my License is in full force and effect.
OM License # Lic. Class Exp. Date
o Z r-- /Date _1/7Z� Signature of Contractor -�
O J
J U OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) 1, 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
11)
O N Date Signature of Owner
rn
Z WORKER'S COMPENSATION DECLARATION
C:) CL
2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q pert rmance of the work for which this permit is issued.
Q U I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
d :LO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ry' T!e 7 Policy No. rD 1��
OJ � r I r.,�i.1.14i7. liLi.+. �.r4d. WC, Vi71i-��zJ.7si s✓
J(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 &S-Rctiion"-3700rof the Labor
3 (Code, �l-s_ 'F IZ �uujth comply w.,it , thoo oviy,
Date: �} / Applicant 1 i1 U
1
Mio
11111 Warning: Failure to secure Workers' Compensation coverage is unlaWf l I 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,toj `
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 -
Z:S7
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 f
construction, and hereby authorize representatives 9f this City to enter upon
the above-mentioned property for inspection purplpses.; g
/Signature (Owner/Agent) �� Date
^ ^ t!
BUILDING PERMIT PERMITV708_4*5 °ONTROL# 3
DATE ' VALUATION �2it�� 0:x,120 LOT � � TRACT �,t� 97�•�4i
JOB
�'FII-.9 '�6%I HERMITAGE
APN 1761-560-021
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ta.SL LAND 11
KS L.1)tVEt.0P&I MW C0I1%i�
Mi -140 PGA BLVD.
X140 PGA t3t,V11
LA q:JINI'A ('.'.A 92:53
LA Q{. CCN I -L# CA X2153
{%,0)773-3647 0.131.#d 4676
USE OF PERMIT
Sof;
kA.t2,eMA, 7. U A.97-Nti, '11 '29i' 8
W [2.3'A( i:::S'LAN ::3A.
ISSO OF SA;44I 1 LAN'I`4Tfi'-
a":,F=t l r l sl.-
SW
e.; Alt At3lY AR sr'
,Hw'a'3N DKSTRUIMOt*a
R011RlWIT WIC :Sb 1 M3e'i ik li
f_1,0 J`3'iA0iZM(')N M'G.ta If 11f)9-4tk�-tJU43 S1, W.S�
PLAN (,"t.WOKFF.F? tF)i (1(1�t>:Y3�1 #(� $'t• ::4
&i;C11AINICAt:I,31's tflt Q[i f wut C Ci �l t,r
O (: TRI+"A•.tr-ssfa .Oi-(:aG•/4cG f#E7c� $t4e2fF$
;i 1 F;C"i¢it i FM'C".t'C!%?.h' F PT - WESIO 1.0141)00-241-01V
GRADING FEE, 101-000-423-000
1_101ir'n !'IZi:IS:`I'U&4[ lrf;E 225-0011443-M2 $di,W)At
J1 'C1.N114 AIMC 'L.FL( 3 ktmC Ijj�r$t31i-13513L ?:3.t)1
R
• C
¢ t '
r q
,�4 i'W, i�`(:);+t�tT1'tF:,1C7f("N �t�11!'Jt P11I,. �`IV �''li_�CK
,b°7/:3p.
r
6A0 l.rf�SS L �tF `C"%`i.t� FMS
A4,5
$0.00
AUG 15 1997 tt<'�;u,�► �; �',rcr �ttr:����i�
".622.45
V 9-N �.TT dA QUINTtr
rRECEIPT
f
DATE
By
DATE FINALED
INSPECTOR
•
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
l
Exhaust Fans
O.K. to Wrap
s.. 7
F.A.U.
Framing
7
Compressor
Insulation
— 6
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall -Firewall
Exterior Lath
.Q
DryWall - Int. Lath
W
Final
rnal
BLOCKWALL APPROVALS
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures .
Main' Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
`Temp. Use of Power
Utility Notice (Perm) 0-%07.
COMMENTS:
Certificate of.0ccupancy
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: 80-380 HERMITAGE
Use Classification: SFD Bldg. Permit No.: 9708-065
Occupancy Group: R 3 Type of Construction: VN Land Use Zone: RL
Owner of Building: KSL LAND II
Td'sh
Building Official
Address: 56-140 PGA BLVD.
City: LA O.UINTA, CA 92253
.By: STEVE TRAXEL
Date: 6-16-98
POST IN A CONSPICUOUS PLACE