9807-250 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby.affirni 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
,� s�1t1L� F3 010('f
Da"te�V / � Signature of Contracto. ✓
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that Lam 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).
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.
MI7It`�1'1�tfi r�a�rc�
(This.section nee nod be om'pleted if the permit valuation is or. $100.40 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�J shall for. with comply wit those provisions.
APPlican � ��
V _ f
Warning: Failure to securers' 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.perso
whose request and for whose benefit work is performed under or pursuantgO
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La.Quinta, its officers, agents and employee
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.
Si nature (Owner/Agent)o"'.w r ���P� Dat&r ;
4
PERMIT #
BUILDING PERMIT
,
DATE VALUATION LOT 9807-2.50 TRACT
$.132.491.71) 32 28545^2
_
JOB SITE`APN
ADDRESS
77-394 VISTA FLORA
631.,380-072
OWNER CONTRACTOR/DESIGNER/ENGINEER
KSr, DESERT RESORTS, MC, KSI, .LAND If CORPORATION -
56-140 PGA8WD 55-920 PGk BLVD
LA QUfNTt1. C.A. 92253 I A QILaJTA CA 92.25.3
(760)564-7166 CBL€ 5323
USE OF PERMIT ^.
_,J e- t ,�
?LAN 2A - 3FP - Wit: nA j DOES NOT NCLUDE BLWK WALL OR POOL.
75TA PLAN CHECK REDUCTION APPLiE19..f.A. QUINTA RESORT t•10WS, `
ntl A A
CUS7'044 Ct`` N8TRUCT[ON 1,6711.f10 Sa•
N)RC11;OR V10 07.0 SI
f�+'yS'l 9I11.ATII s1 COSI C1t11f CONS�TRIIC'�, ION
132,492,78
:3y yy �y. �v;7p,. p
,cd .�{.NIf 1 FEE �aHiJtii-Ir�t� R
CONSTRUCTION FEE .10.1-000-418-000 $755.00
'PLAN C1ECK Fa 101-000-439-318 31460.21
t0ECHA'NI6kL FEE ' 101-000 421-000
6,fiC, .fRiCAI,FEE 031.09
PLt Ntl3fNG•.FE.E 10.14000.419^1100. A17•11.50
.
�YffL JNt M(XI'1CN 1 R1 .- RE SID 101-400-241=000 $.t3.'
GA'AWNG Me 101-000- 421-000 Sa�:Oii
42 5?,93t.i4
INFRA-'TRLICWft FRE 2254" 443-3,42
ART IN PUBLIC PLACES =:RESX 701-000-2s5-000 X51.23
t
w �
SUB IMx L C•ONS'r P L1C`I'ION -IND 1'I;.AN CHECK
$4,361.88
I 'SS PKF-PAM FE.69
'W'00
Y
TOTr�lJ PEiCiO IT FEES DUE NOW
84,367.88
eft �jt
•
RECEIPT
DATE
BY ° """
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
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
- 6/
Compressor
!'
7
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 L
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
--, 7 fj
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
,