9809-045 (SFD)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 # Lic. Class Exp. Date
' N
'7471uro $ �f�l �✓Ym� ijl �iiiW .
Date 7 6 Ash Signature of Contractor - ' u1. 1
<t�
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).
(• ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Seca 7044, Business & Professionals
Code).
O 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
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.
r _ "G' it�gs rRaY`
W, 21199
0o 1 21199
on ts 06
(This sectinee not be complefed if the permit valuation is 00:00 or less).
( ) ,1 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 th . e provisions. may. l' ✓0, �`'�;✓`
Date: !;r!Z /4s¢ APPlicant `'1.,'�.s�•<e} r� e !`.,
Warning: Failure to secure Work/Comp ensation'coverage is unlawful and
shall subject an employer to criminal penai4ies'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. i
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 becomesnull 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 inspection purposes /; `
57 40604.11— A
Signature (Owner/Agent) £i.Lfc �5.. Date /,
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 9809-045 TRACT
19 ,449. 41 3 `28545.2
JOB SITE t(:
APN
ADDRESS.:;
77 'x00 i 1Sl1'A FLORA
631-384-032_
OWNER, CONTRACTOR/DESIGNER/ENGINEER
�,,SL 'n1_,,SE,kT RESORTS; INC, KSL LAND If CORP0fU,TION
.36-140 PGA BLVD 55-920 PGA BLVD
1.,A QUINTtt CaA. 92 253 LA QUINTA C.',A. 92253
t160)564-716 C13L# 5323
USE OF PERMIT
LOT 1, AR 2. PLAN 3 - SFU - FtMiff DOES NOT INCLUDE 13LOC-
NVAIX OP,POOL. PLAN CHECK F'EF.s.REDUC' aD 750% FOR MW TIPLE
ISSUANTrP OFSANIE
CUST014(C0NS'rKUCTItON Z.391100 S?~
PORCHIPA.TIO 691.00 SP
E.S INI.A FED COST OF CCDNSTRUC` LION
1915,40.20
PERMIT FEE SUMMARY .
CONSTRUCT (ON .FM 10'1-000.418>000 $975.50
PLAN CR CK FU 101-000-439�318 wft'.JS
M1XHANICAL M. ° 101=000-421-000 $118,00
a L,1sCI-RfCAL >±IEC 101-000420-000 $141.119
PLUMBINO FEE 101-000-.4.19-000 $1.98..50
sr.6LOING'N10TION FU -'R SID 101,000-1)41-000 • S19,54
'GRAIDWO FEF:' 101-000-42. 3-000 $20.00
NF RAITIRUC I U0 FEE 225-000-4�3-342 $4,190,83
s�f2'i:IiiPU}iLIC.,NI ACES-RF;SM'701-0011.255-000 $'23$.62
4E M
AL3 DAL CONST, UCi'ION AND P AN C'.LIJiCIa
1C105,16
LESS .PRE -PAID FEES
K(yu
ND.V 0.2199 '
,
T0TA PE tr%ff FEES D1U'E'1 OW
S6,105..16
{�v ..3A
tM: s• r •.
RECEIPT t
DATE a
eye; u
DATE FINALED
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
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
Final
Final
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
Final
Utility Notice (Perm)
COMMENTS:
'