9701-022 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
G;,apter 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'
_547732. B .--
/Date - 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.
( ) I have and will maintain workers' compensation insurance, as required by
Sec ion 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.
4. tKII IN10,. Co.
WC6338%505
(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
/Duat
bject to the workers' compensation provisions of Section 3700 of the Labor
ode, I shall forthwith comply with those provisions.e: --z Applicant—
Warning:
pplicant 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 aid
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.
I
Aignature (Owner/Agent) t,4' �' t %r'D tae :Y7
PERMIT PERMIT# CONTROL#
BUILDING PERMIT'9701:-0 Z 4 8 8 Q�j
!!
DATE � VALUATION �1��11<.•fi.ff LOT �j TRACT �h I �
JOB SITE
.fi1U- >I�.1��.KIY {: .Et.E{aSi {J�tl�k•��A
ADDRESSA
PN 761—.7.~50°•' 36
y-OCNNER
CONTRACTOR /DESIGNER /ENGINEER
K_�;t, LAIND 11
KSL DEVELOPMENT CORP. _
>6- i4O .PGA BLVD,
- 56A0 PGA ROULEVARU
LA QUINI'A CA, 92253
LA QUINTA CA 97253
(760)771-.tfi92 417BLI€
USE OiiF,, PERMIT
110A WtiS'T-11HRITAGIR 111,AN 3A
PLAN C IVC'K Frit- HFIAXED F0X M111,11ME. JSSW)•3 OF SAME, PLAN
i;1 MOM CONS l",:tlCx'7{3N 3,441. 0 fiF
111OR01 Ul*A'i 10 519.W 3
c1AItAc)):1c;Ait1R r 5433.00 SF
MATED COST OF t:ON9TKtlit.° 1'101
236,383.40
ii%yr�SYTI
t't.�llCj!'%3•�• �i'.e� .1�f1�fE�%*hf1;l-
00NS1'RtJ(:FfttNFLTM 1()1.000-418-M
P IAN 011171 Frii 31,44.23
I%tI?.(.IVV41CA1, FEES t01-000•421-000 $111.00
111,1WifIING t•'EE'4t I()1-t!{IE1-iii!?fid 52132-S
grirIONsz MOTION S":R64
OIZADING to (-000-41,13.1X00 $20.00
f Nf,1ttV:+"P1.t�:1'llitl', 225.0W-443-342 Stoi,"mki
AWI' IN WYI`41.19� (141i119 7111-(100-255-10) S4405,W
s
. t
C>< f# i'Y1*Af, ct:)ht r`T'C:t1G"( ON AND PLAN C111"CK
$8,599.68
[AAR 2 7 1997 TI)` All, PERMIT IFFPS. 11113i? NOW
RECEIPT
DATE ;
BY;
DATE FINALED
INSPECTOR
irt�,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS,,
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings h
Ducts
Slab GradeReturnAir
Steel
Combustion Air
Roof Deck 5
Exhaust Fans
O.K to Wrap /
F.A.U.
Framing r
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath 7
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 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 ga
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)
i
OP LA OIJIN 4 J O N TAN DY
APR 16 REC°oY
Yucca* Valley, CA 92284
SPECIAL INSPECTION ' � 619) 365-5045
CEREGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE TRUCT. STEEL ASSEMBLY ❑
O POST TENSIONED CONCRETE O ASPHALT --B'OTHE. RN -h,4 ��N^
❑ REINFORCED MASONRY O FIRE PROOFING /— 7
JOB LOCATION _ /Alt) v j44k— /V //Ck4AVS
%\
Uf
REPORT SEQUENCE NO.
TYPE OF STRUCTURE 16F,)
PERMIT NO.
DAT g _
7
DAY OF WEEK
MATERIAL ESCRIPTION
W -3 4-500
ARCHITECT
INSFjECZ r`
J r4'�cV11
HRS. CHARGED
-7—
/ /
•y
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL `T'
DATE CONTRACTOR ' 1 L `
SUB
CONTRACTOR
�D Cvmne(�T/o
/ (:)r-
4
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COPY SENT TO CLIEN
CONTINUED ON NEXT PAGE O
PAGE OF
/ N—
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
SIG ATU E ^F WQISTEREIt q TOA ^ � (q
TE I OF R P RT REGISTER NUMBER
Certificateof Occupancy
City'ofta. Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 56-440 JACK NICKLAUS BOULEVARD
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9701-022
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: KSL LAND II Address: 56-140 PGA BLVD
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR.
��yLl
Date: 9/24/97
Building Official
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