9807-259 (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 # l' Lid. Class' Exp. Date
74786 '� 40100
0/ate Signature of Contract 2, A/., e
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).
O I am exempf 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.
(V) 1 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.
(This section) ete�o 36aeLcom eied if the permit valuation is 00. 00 0 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 wl"t those provisions.
bate:', J04 Q h?"� Applicant Ni?: X& /
Warning: Failure to secure,/ kers' Compensation c' "overage 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 setforth on :hise`
application.
A 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 y
construction, and hereby authorize representatives of this City to enter upon
the ,*above-mentioned property fo inspection purposes.
i nature (Owner/Ag ent) - 7 - Date / - 0 1X✓
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 9807-259 TRACT
11f9:919 5195.449.20 16' 28545-2
JOB SITE
APN
ADDRESS 7 3
71.4 VISTA FLORA
631-380-072 .
OWNER . CONTRACTOR/DESIGNER/ENGINEER
KS�L DESERT RE -S, INC. KSL "LAND it C:OI` P RATION
VTC
56-140 PGA "ALVD 35-920 PGA BLVD
LA. QUINTA. C.C.A.922.53 LA. QUOIN rA CA 92253
CSLW 532'3
USE OF PERMIT
�JC'..�
c� ��•
la
PLAN 3 : S��-1'�FcMi i` t"7t3L9 Nar �IC-L3:1iye, m. WK wAl..L oit Pooi..
i.5% PLAN CHECK REDUC'T.ION APPLIED. I -A C�UJNTA RF`SORT f�()mES,
U .'
C"V15T011 COINST UCTfON ;391.0 Sf:
POkC-f'XtPA 'iv . ti91.QQ SF`
CS' IMA TED COST' Oi! CONST'.d1;i IfflON
.19514 49.20
4'�.t1;I4�I FEE 9i3li MARY
CONSTRUCTION .FEE 10,1-000•�1,i 84M $9,115.50
N, AN CHECK FEE IC:I�U()0-139-3IS "$202.98
IVIDCHAMCt�L VD, 1.f 3.-i t3Q-�i2f.t1(i0 sf1.sbo
ELECTRICAL FEE 101-000-4. 0-000 $141.19
PLI:f1MR[Ni friE - 101-060.4199 00 1`753. 0
STRONG MOTION FEE.FEE.- i�SID ,101-000-241-000 $19._`+4
GRA1atNO FEE 101-000423-•000
l ila:ltA r3`! 1117{; I iJIS ,F F �; 225.000-44.3-342 ' $11,1901,33
TART .(N PUBLIC, PLtICW$ fiI��TC 701-4)00-2.55.000 $238.62
n
SUB-T(YfA�. CONST UCTION AND PLAN CHECK
$6,105.16
IMS PIZ1s-PAID FEES
TOTAL PERMIT' FEESS DUE NOW
` 6.105.16
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Q - 2_ -
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
OX to Wrap
F.A.U.
Framing
G _ -15i
Compressor
InsulationVents
I
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
G
Drywall - Int. Lath
2
Final
Finat- — -
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"A
le7
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
- -Di l
Appliances
Final
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 - O
Utility Notice (Perm)
COMMENTS:
-