9809-063 (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
1.
Date ',/`7' Signature of Contractor �-fi* - •' l� -�'
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' r
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.
�:LI''r ;tdt4 �1iti"��"c7�C9, V�` "E,���9 �t a
(This section nee not be comple{ed if the permit valuation is for $100A0 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 forth sllh comply with those provisionsl�i `' fiT a
Date: Applicant—
Warning:
pplicant 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 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-mentioned property for inspection purposes 1/,r
Signature (Owner/Agent)✓�'�:. 4Zf Date dry ?I r'
4V el :y "
.r
BUILDING PERMIT PERM T#
DATE VALUATION LOT 9809-063 TRACT
JOB SITE
ADDRESS
APN
OWNER' CONTRACTOR / DESIGNER / ENGINEER
.KSta :DFSFP,T RESORTS, WC. KSL LAND It CORPORATION
564.40Pt". A BLVD j M-92.0 PGA BLVD
LA QUINTA Ck 92253 LA QUfNTA CA 922$3
`t (760)564-7166. C•13L# 5323
USE OF PERMIT
, i\1 •_y. ,2 i: ' +wa" Tr 'lY''i'` 1` iso`.+..
LOT 28, PH 2, PLAN 1- -STD .- PERMIT DGES NO C .MCLUDE B ,OC
WALL OR POOL. PLAN CHF..t:K. FFE RYDI ICED 75%`F'OR MMTIPLE
f sst YAwep nrs A ,, F
e
OCTS'I`.OM CaKS`1 RU SON 9A00 SF
PORCT1(PXTIO 243.00 a�
T
0ARAGE/CARPORT 1, 190 00 w
- to?�l,l ':IIL"s l..P�.�i �:�i,7�1 'iJi� .•J'1 �.�l.i.i�f:; 1.,1 M�.II'Y ._
i'i.J'4.i.A
PEiRMff FEE SUMMARY
CONSTRUCTION FEE 101-000.41.8-000 �i39.5U
PLAN C1WICK EBE 101-W-439~31$
MECHAINICAL I"L I01.000-421-000 �S?l i0
1.01 -000-420-000 149.
PLUN03ING FEE 101400-4,19-(300 � 13�3:t1i3
STRQ_NGN1Uf10NF11: kESID 101.00-241.000 19.,93
GRA1:t'.rNG FEF• 1131-000.423-000 2ii.01)
RAST zUMME, FTE 225-000443-34? 0*2,16a:86
A..
. 93- "C17.'AL COINS'! RUCTIOINI AND PLAN CHECK
f .LESS PPM -PAID FEES
$0,00
,AL TEf(iAW FEES DUF NOW
�3,2g1i.5®
V i
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RECEIPT :�J
DATE _�
c
-BY
DATE FINALE:/VD
INSPECTOR
tj . ,�
- — 9
.
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
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 I
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
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.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)