9712-002 (BLCK)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
%� .�''.
Date Yl d 1 ���Signature of Contractor
OWNER -BUILDER DECLARATION
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
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.
(1 1 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.
1111, Ti:1,11TIND t4V4 V-11
(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 jthat if I should become
subject to the workers' compensation provisions of:Section.3700 of the Labor
``Code, I shall forthwith comply with those -provisions ,
bate: �. 12— "- Applicants �i +
r
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
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
I
e above-mentioned property,for inspecti6h purposes. ,!
J Signature (Owner/Agent) `' ' Date /
BUILDINGPERMIT
PERMIT#CONTROL#
DATE 1/97 VALUATIONss.�K►n•f>II LOT
TRACT 6345
JOB SITE
ADDRESS �"�:����-i=C•i i R►t�IC..T �.R,1+>;'1�.�?�>t�.13L.�
APN '
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1 r A N1 VI Ire,•r
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IY\I W.I\rc�rv��*1
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•!"'w't+>'tivri5fi NG1'0N q*. F-233
LA til.JINI'A CA 92253
f'AI.,M f'f1 SINT CA 9212111
17frt11'�++f?-127�� (:Rf •tl 6R6
USE OF PERMIT
itSiJif•1Jlfti�:i
2ZW') t.,#'o 0 11f1,RIAN WALL, LLQ (. j7<.CC4 S t 5'f'unf.
LOTS 1-14, TRAL t' U -t 10. t1HA,38 3
6 F"F', W&J,
E+;—IT3MA•s E'D Cart'
OF CY.".'�cSTIMI's::ION
501.UJ.:M
Ct*ITR our 10N, F111 1()f-wo-4tii-ti(i(# 5437.00
f
r
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12'C,tF+f;4'f'fiOMOj±,i.ANO PLAN CiiFi K
' $417,0111
LESS ('Pali -PAID FEE"'?
SOA)
TOTAI!, PERMIT i!: UMN MW NOW
5137.{Nt
RECEIPT
DATE
BW
DATE FINALED
INSPECTOR
If
•�A
1W
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS -
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS
- SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I 2 —
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
44 G IV'?
�� �.g*t%
<
Fri l —3
/,SB — /� 2-j
t
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS/c(1
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
It t
78-105 CALLE ESTADO — LA QUINTA, CALIFORNIA 92253 - (619) 564-2246
FAX (619) 564-5617
June 18, 1991
Imperial Irrigation District
P. 0. Box 1080
La Quinta, CA 92253
Attention: Customer Service, Office Manager
Reference: 79-875$ Pecan Valley, PGA West,
La Quinta, CA 92253
Dear Office Manager:
I would like to change the above referenced address to a new
address closer in proximity to the actual physical location of
this meter.
The new address: 55-9951 Jack Nicklaus Boulevard.
This meter temporarily feeds the Jack Nicklaus Private Gatehouse,
landscape, irrigation and lighting, as there is no permanent
power available at this time.
Sincerely,
BUILDING AND SAFETY DEPARTMENT
Tom Hartung
Director of Building and Safety
TH/lc'
cc: David Firestone, National Mortgage & Land
PGA West Field Construction
Bruce Frazier, PGA West HOA Rep.,
Resort Community Management
MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253