9807-247 (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
7478605 B "�1 4f 00
Date Signature of Contractor
V OWNER -BUILDER DEC—LA�Ri ON
t• -Ir
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).
() I am exempt under Section B&P.C. for this reason
Date Signature. of Owner.
WORKER'S COMPENSATION DECLARATION
1. 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'
recompensation, 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.
, R1 4wC" 1491M
ob2 hm100.00b
less).(This section nee neco P.
(') 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, I shall forthwithcompI p wit ose rovisions. /
)54e: 1 /n. Applic nt ,?, J' ✓ ✓ y
Warning- Failure to.secure VGorkers 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 person aY
whose request and for whose benefit work is performed under or pursuant tt
any permit issued as a result of this applicaton agrees to, & shall, .inde rYify�.
.& hold harmless the City of La, Quinta, `its officers, agents and emplo ee`s.
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.
Ig ature (Owner/Agent) /01 `• �' Date - �'
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 9807-247 TRACT
$1.9S,44..9.20 43 :28545-2
JOB SITr P ` ,, a
APN
ADDRESS -i J
77-1, visTA;Ko.RA -17 - 4 34
63148l1 -f172
OWNER CONTRACTOR / DESIGNER / ENGINEER
KS ID SERT RESOus, :1NC; KSL, LAND :t1 CORPO1'XIMON
,56-1.e10 PGA T3LVD 55-920 PGA BLVD
LA QUNI TA Cil 92253 1.A QUYNTA CA 92253 •
(760)564-7,166 CBL,# 5323
USE OF PERMIT
P
£��.t� 3 8H?�- P,ERIvI1T,131aL,S 'Nq T 'ti7Ci1 �3�OCii` i7Ji�ii'L t�t2. isc7C)"L:
75% PLAN G:, HFgK REDUCTION f .!I QWNT'.4 f SORT.HOA4t,S.
T
9
CUSTOM CONS'.1 R(JC7.1ON 2,39 1.00 .14F•
PORICK1'Pkyto 691.00.5
1 S`i1MA D COST OF CONSTRUCTION
143,447.20
i'L;R&M FEE SU2M1 URY
C3NS'r";EtITMON F'ER 101-000-418-000
'PLMN CHECK FEE 10,1-000.439-318 $202.98
MIRCHAN;1CAL FEE101-000-�12 k-(��1t) I i;1a�G
kLF'TRIC,ALkUa 1.0.1-0004420-000
k*i,t.flti113INO:HIE IOIA00-119-000 8198.50
STItONCx N O'PION Pte. _ Itl:;SID . 101-00fi-241-000 $19.54
GRADING,FES 101-000423-000 $20.00
1 4-0- .443-342 �,i9u.�14-AiRI50
AST° 1rf PtfgH.Hc �r„ASS ..R.r.�gr>� 701�OCJ0-755-000 ��$.F'
SUB -TOTAL CONSMUC"1"ION AN•D PLAN C IEC-
St►,lOS.I,��
'LESS PU-P AID VE S
Woe,
:.... , . , 'TOTAL, .P: -M-11T FEES DUE 1V()W
$6:,.105.16
v
RECEIPT
DATE +
BY T ” .�-'L--
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings ' _
Ducts
Slab Grade i
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 OZ
Final
Final r
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
Pool Cover
Sewer Connection -
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 17
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:
'