9812-237 (SFD)LICENSED CONTRACTOR DECLARATION, a r
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
r"Prafessionals Code, and my Licensees in full force and effect.
License # , Lic. Class Exp. Date
,..,w \ �:...
'' 7sef�cGli ;3 eil3t�ltx?
/Date ��+ Signature of Contractor
OWNER -BUILDER DECLARAfTIOt
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 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.
r�nirtLf. BkM+.1..Jg.lyn1•.. bry. V+i.70r�iJVf1tibY".Ax
(This section need not be completed if the permit valuation is for $100.00 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 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 Sectio 3 ,00 of the Labor
Code', I shall forthwith comply with those p, ,IslCs�
, Date:/ L Applicant
Warning: Failure to secure Workers' Compensation -coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of. compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
fora permit. subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall,. indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance.of such
permit, or cessation of'work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws. relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Si nature (Owner/Agent)4/ Date �P ✓r
(_7"
f _ 9y. i a .
`r PERMIT #
BUILDING PERMIT
gOzz
VALUATION �`:.3,i�� ^� LOT TRACT 7KS.QY`-
DATE{ /U'
I77-4ii)
JOB S'/, tl
ADDRESS VIS.@.lits.l��$.i�.D�. A .
APN 631-370.422
OWNER
CONTRACTOR/DESIGNER/ENGINEER
BLVD
55420 PGA r LVD
LA QUINTA CA 0253
LA Qi31NTA CA, M53
( 76OW311 710 C0 5323
.r
USE OF PERMIT
sm. Low,58, PLAN 28. PERIVfIT I)C)LIS NO}r il4 UCi"+l liLOCK WA :L
OR P001- PLAN-QWCIS F'Hlr• l E0UC ',1i 79'30 kt]fi. Mi„11 IPLE ISSUANCE; OF
SAW !?l, AN I'S'1gRi .
CUSS'11'01\4 CONSVRTICTION 1.67 ,00 SF
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CO:INS'i1i1:1 "TiON'1 EE 101 -0004M -WD
PLAN C IFICKr
A,IECH� IRICAL PM- 10.1-000.421.000
ELEI:IIIIL AL
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OTGV0I140 Fel t' 101.000.423-0110 3.20.C*
T'lTtii:l I 2,23-000 4
AW.I' iN-P-U l,ICPLA\,C.Ei-.f2.r4,$Eu 101-M-2,s5z000
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�4 3d§7.�if4
ILES5 RRE-PAID FE -tS
$0.00
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RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
-- M
INSPECTION RECORD
i 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
2.
Final
Final —
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
I I
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
. Ud
Appliances
Final
Final Gam/
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 C(/
Utility Notice (Perm))e -
COMMENTS:
Certificate of Occupancy.
_of La
CitY Quin ta
BuildingandSafety
. eetoTti
This Certificate issued pursuant to the requirements of Section
certifying that, at the time of issuance, this structure ,was "n com 09 of the Uniform Building Code,
" of the City regulating building construction or use. ,For the fo/mPl i nce with the various ordinances
' - g
BUILDING ADDRESS:
77-450 VISTA FLORA
Use Classification: SFD
Bldg. Permit No.: 9812=237
Occupancy Group: R3
Type of Construction: VN , Land Use. Zone: RM
Owner of Building: KSL LAND 11 CORPORATION
Address:. •55-920 PGA BLVD
City: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 3-14-00
Building Official
POST IN A CONSPICUOUS PLACE
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