9809-058 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing witli 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
747866 1311.7 4tx/4130100
Date tai,1, Signature of Contractor—CIV j�• rj , y'
OWNER -BUILDER DECL'AR TION
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)..
( ) Lam 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: .
7..I,'R:ICH INSi�''RA ICE `�ilC68389M6
(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; l shall forthwith comply with those provisions.r, 00
Date: -r Applicant ��
Warning: Failure to secure Workers' C9mpensation =ion 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 pursuanVto
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 asa 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.
145- .. fl�A-.:df�, y
Signature (Owner/Agent) " ✓X>! 4Date
BUILDING PERMIT PERMIT#
DATE -. VALUATION LOT 9809-058 TRACT
$130,472,0023 28545-2
JOB SITE
ADDRESS
APN
17--270 VISTA FLORA, .
631.330-032
OWNER •- CONTRACTOR / DESIGNER / ENGINEER
KSI:; DESERT RESOUSA INC. KSL :LAND I1 CORPORATION
56-1,44 PGA BLVD 5 2{f PC SLVD
LA QUfNTA CA. 92253 LA. Q MITA CA 92253
(760)564-71.66 CBL# 5323
USE OF PERMIT
ti' N:iE"' "r 1 A . i ..v .. CAS" . , Tr'
LOT A P.II 2, PLAN 4D -ALT - 91—D PFRNGT'i URS NOT MC IJOR
BLOCK WALL OR POOL. PLAN CHEsCK FEE RF.DUCFD 75% FOR i IULTIPL;
fSSUANCT_ 0V SAfAE- PLAN TYPE.
CUSTOM CC1 gTRUC:fIONI , 1,680.00 SF
CSTIMAT QLD COST OF CONSTRUCTION
113Q,?I�a.{R►
PERMIT FEE, , SilMM ARY
CONSTRUCTION FM 10,1-000-418-000 $748.00
PLAN CHECK FEE 10100"39-318 x'160.1 S
NECl AaIMCAL'I; .1.01-000421.-000 $1'37.00
:k LEC'i"RIC L FIX 101 -000420-0,00 $116.30
PLi1N B.1NG 1' E14• 1.01=000-419-000 $169.75
'8'.f.1IONG MOTIONFEE - RESW 101-000-24:1-M 83.49
OtzADi'Nr YU 101,00042:3.000 $20.0
i FR.A.S`i'1iUCTU1 VEE 225-000-443-342 52,9144.52
A'R71' W P'L' BL[C:PL}AM -;RESIA 101-{JOt 255-000 $77.18
t ,
SR 1
-101'AL G'�?NSTRIlCtiON AN1 .PLt�hi t;TlEC1
1+1,185,09
- 199 LESS PR -PAW l>I F3S
V.(�
PERMIT FEES DUE NOW
S4.386.09
e
RECEIPT
DATE
BY :
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
0.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
Neater 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: