9807-253 (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:# Lia Class Exp. Date
147866 )3 4f30%30
Hate d— Signature of Contractor I, a
OWNER -BUILDER DECARATION
I hereby affirm under penalty of perjury that'l 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 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 wilf maintain a certificate of consent to self -insure for'workers'
compensation, as provided for. by Section 3700of 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
Se .[ion 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:
Carver �T Policy No.
(This sectio need not bei' ompleied if the permit valuation is�for100 00 or less).
O 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. w 1
./Date: r Applicant o 1
Warning: Failure to secure Workers' Compensation colverage 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
fora 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. l 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.
nat,
r�
S'gure (Owner/Agent) n /� 1 �°�� Date
�. = ✓' 710
BUILDING PERMIT PERMT#
DATE VALUATION LOT "07-•253 TRACT
$1.32,402.7035 485454
JOB SFTE F '0
APN
ADDRESS
17-.370 V1 %TA r,LCaRA.
631,180-072
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KSL DESERT RESORTS, INC.
K.SL LAND 11 CORP R ATtON
56-140 PGtt'isM
55-920 PGA BLVD
A QWNTA CA- 92253.
:LA QUINA Citi 9.22.53
(760):564 -?166 CBL# 5323
USE OF PERMIT
SP GILEP.A-14-A.
c.
PLAN 213 - 0A.-:PhucNi e D00 NOT INCL3JUE l fLQCK WALL OR, POOL.'
75!'/o:PLANCRECKRE.l UCTION AP['1.'WD.:1.fiQUIN'i.'A.TCF. OR.T HOmFs,
I
Cl3S:1'( 'Rri:C 'i�f�3i'}�:tJC"['it7Td 1,6141.00 SF
'PC3ii.CJ'i'PfkaiO '1,S�.tiO St�
LSTM'IAT, I D GUST OF CC1ietST[3Lf('.`8 "IN
1:32,492.711
FERMI FEE Si7SIMARY
CONS111R C'r1OWFES 10.1-000.118-4300 $755.00
i>z AW CHECK rEla 1111-000-09-.318 $16113.21
bIAiVI�NAL FER 101-000-42.1-060 $9&30
Ei:!?C i`1�1Gt11.F:F 10'1-000-420-0011 $131.09
isi.L.lNMINO FEE: 101.000-419-000 $174.50
S Y1 RONO MOT110N:FEE- MID 101.000.241-000 513.`
CRAA11-10 FIM 101-•000-423-000 040.611
1Ni� 17.AS'TMICTI E FEE. 225'••000-443-M $2,934.10
ARZ' ]1kFPU8L1C.PL,AC FS - RFSIL 70:1-000-25:5-000 $31.23
h
SUB-TCyF4UCONSTRUCTION AND PLAN CHECK
LESS PRS; -Fa: ,O rTES
"Ra.ot"
TO T-4iL FERMIT FEES .DUE'( NOW
�r9;3fi7.88
RECEIPT
DATE
BY
DATE FINA D
0- a- - 99
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 PI . 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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: