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_ LICENSED CONTRACTOR DECLARATION
I hereby, affirm under penalty of perjury 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.
License # Lric•, Clas Exp. Date
-1
7
/Date ��' f 7 Signature of Contractor �f
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury 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 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.
( S 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.
Zl!'C ICH TINS. CO. WC 6S0196505
(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 of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.,
VDate'
: i 9WApplicant 11///AIV
Warning: Failure to secure Workers' Compensation coverage is unl� jful 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.
BUILDING PERMIT
DATE > Z Z9t� VALUATION. � ��3'S � � LOT
JOB SITE
ADDRESS 80-4716 HERIN' .Q ACr.E
OWNER
f<; SI., L.AINT.i31;1
35920 PGA BLVD.
LA Q[AN`1'A.
USE OF PERMIT
ADE
PERMIT #
13
APN
CONTROL'#
TRACT
CONTRACTOR / DESIGNER / ENGINEER
iH
140 PQA IRM)
z.A. 92253 ' LA QUINi'A CA 92251
(760)5.04-7165 Cffll 4676
PfutCO3, 1:3,11,A.97 -2A6, Tit 281 N.
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PCIRMI o. FIR C .�`4Sl�,iS1ARY
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101-000-439-318
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1011-tt{)0-41R-000
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S'17R01-40 MOTION FOR, - RE, STID .101:-13
O.2,,41-000
Cl1ODINQ1111 F.r
10:1-000-423-000
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571.)9
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 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
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-mentioried property for-inspectiori purposes.
t {
ignature (Owner/Agent) " l + Date
Vr1..
`u Jit3� 1 t r 1 Ar t C3N 9' t TC`1"f,C71 A?�i11�T 1(, ME _'N'
LESS Mr. -PAID FEVM
TOTAL P EMIT17 1 EEE OUE'1TC:1W
DATE By DATE FINALED
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$.5178.52.
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 I
Exhaust Fans
O.K. to Wrap a��J
F.A.U.
Framing Q
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 3
Final- �'�
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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 4�
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G:E.I.
Smoke Detectors
_Temp. Use of Power
Final
tU tyr Notice (Perm)
.f�
Dec -29-97 14:45 CVUSD - FACILITIES
Coachella Valley Unified School District'
P.O. Box 847, Thermal, CA 92274
(760) 399-5137, Ext. 235
619 399 4414
This Box For MOW Use 0*
P.02
CERTIFICATE OF COMPLIANCE
(Government Code 53080)
Project Name: Date: December 29, 1997
Owner's Name: KSL LAND III Phone No.
Address: 80-476 Hermitage, LaQuinta, CA 92253
Project Description: Addition to Guest House
APN: 761 650 015 Tract #:
Type of Development: Residential XX
Lot #:
Commercial Industrial
Total•Square Feet of Building Area: 365
Certification of Applicant/Owners: The person signing certifies that the above information is correct and snakes this statement
under penalty of perjury and further represents that lie/she is autorhized to sign on behalf of the owner/developer.
Dated: Signature:
***kkkkk*************k*kkkkk**k*k*R**k**k*k*kk**kkk*****************k***k***************k**k
SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE
SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE ONE):
Goy. Code Gov. Code
Project
53080/65995 65970
Approval
Number of Sq./Ft.
365
Amount per Sq/Ft. $
-
Amount Collected S
-0
Agreement Existing Not subject to fee
prior to 1/1/87 requirement.
Note: Pursuant to AB -181 any room additions
or enclosures of -500 sq. ft. or less, are
exempt from developer fees.
By: Foch "Tut" Pensis. Assistant Superintendent Administrative Service
Administrator in Charge
Certificate issued by: Marcela Valdez Signature: iLJ
N(MCE: Seaiwt od010 of the l:ovenwMlt Code ancted as Assausly Bill MI. set forth as Chapter 569, uattrta af0w State of Womia. 19% ellective Ian 1, 1997, regv&es tlut this scimi nd tuxl iovide a written no1�x a
dx project aypliata at the lime cfpaymma of school fed, utitigatimt payment or othu ametimu. 7his,to "is to advise yon that any protest in regard to such antotntts or tlx validity thacof of to with Seelion 00010
ofdto UOventltlent Code and otltd 4whobis law. ccamtmtcee with suds paynma or perfmamme of any otlm repdan>te d as desaibed in secGw 00020 of the uoverramd C:odc. AddiUojugy. tlta tm ice advises dmt dte
proiW 0moof mum% omit wiWot 90 calesdm days Uttaea8a.
Note: AB 2926 and SB 201 fees are capped at $1.84 per square foot for all residential construction, and at $0.30
per square foot for commercial/industrial projects. ,
ct
Dev. Fees Disk: MisclC;erbC um.Sam (REV. 1/97)