9807-251 (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
7 y866 a B 4 '00
ate �� Signature of Contractor - - , r -
' .OWNER-BUILDERDECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 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:
Cartier Policy No.
(This sectionirtiBei n�t'befl omp eted if the permit valuation is for.$1'00.00�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 .mariner so as to become subject to thee,
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 -t ose provisions.
Date,- � `� Applicantsf }�yWti 1 /i %%%Jr �
Warning: Failure to secure Workers' rcoCompensationverage 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 Directorof 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.. /
/�gnature (Owner/Agent) % Date
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 9507 251 TRACT
Arl $132,492.70 33 28545-c
JOB SI_fE1 I
ADDRESS
APN \
\
77-386 VISTA FLORA
6:31-38'0-072
OWNER CONTRACTOR / DESIGNER / ENGINEER
KSa, DE.SEkT 1Z .SORTS, INC, KSL LAh'D 11 CORPORATION
36-140 PGA BLVD 55-3.20 PGA BLVD
LA. QUINTA SCA 92253 Ltd. QUWrA CA. 92253
(764)5614-7166 CBLY 5323
USE OF PERMIT
• �vvP_��In
RLAN 2B - S1 - PERM i INC U.DE 13LC tyre W AT..t_ OR. POOL,
75%. PLAN C ,Cfs..REDUC. 1 rON APPI IM. , LA QUINTA. RESORT HOWS, .
T A lqr, '
CWTONK COld;NFRUCTION 4674 'oil SW
POit(.�HLPato 157.66 ?I'`
Ll�:� IMATVI D COST OPCONSTRUCTION T.iClN
1:12,492.70
PERMIT FEE 9Y.11bMAR`3=
CONS ''RUCf[ON FMR, 1.01-00041R-060, $755.00
.PLAIT CHECK M, . 101-000-439-3,t8 $150.21
;ViFCf4A,NiCiSt. ..101-00o421-000 $98.50
,CAS FEE -U0FXEC!RI10$.131.09
1? xmilI ING FFE 101-000-419-0(30
3TRt3NCiAI CION FEE. -RE -SW 101'-000-241.000 $33.25
01PLAUNIG. ME101-000-4'23.01 0 $20.00
1NF:t3."fRLJC("i3" "F8 2.15-000.643-342 SZ 934.10
AWF W :PUBLIC PL,AG'tr4 .111351r; 701-000-755-000
SUB -TOTAL CONSTRUCTION ANDPL_ N CHECK
$4,�'�7,8R
LESS PRE -PA D FEES S
$0.00
TOTAL PERMIT FFES DUE NOW
$4,:167.88
RECEIPT
DATE
BY �i' " �"'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-2- .
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_ A
Return Air
Combustion Air
Steel
Roof DeckAz
47
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
y
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
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)