9709-088 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby, affirm ur3der 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 .#jj g Lic:,Class.. Exp. Date_, (S
42
/ate l Signature of Contractor / 1 to ! ,
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).
( ) 1, 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
Sectibn 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,t»s,,� r-, r�, r. Policy No. W &13396505
(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 Section 3700 of the Labor
/bode, I shall forthpith ith comply with those.
YDate: C- ' Applicant -� -v
Warning: Failure to secure Wor ers' Compensation coverage is unl ful and
shall subject an employer to criminal penalties and civil fines up to $140,000, 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 Buildingand 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 .
the above-mentioned props rty^for inspection purposes. /
/Signature (Owner/Agent Date 15
PERM ITCONTROL#
BUILDING PERMIT
DATE �� , VALUATION �,:+at a_ zt�ti LOT ; TRACT "� '
qlve
JOB SITE F .)dy- iGi:{14 .'�t l,.11.. ��., .�,al�: f
APN ib i_;.±4936
440
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LAQUIN'T'A Qk !)2251
LA Qf.l NINA CA 'x2253
(;'1tSf#jSt� 7►fid CRIS, 1676
USE OF PERMIT
fii�'.l� - c��T3�ii. %�.aiv �k��"�, T.r�s �':�i. ��I...� �•'�3�i.�'A �jvi<.'ti�.JN �r i�:€:'�:>
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It 5,00 SF
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AK!V fN PUBLIC; Vt:rflCIZ'N, 101.-�U(i0- 2_'5 -000 1.11
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' a g';XL J ?€'Rhi�'�' .FRES DUE, NOW
$6,45440, 5
2 61997
ISE?* .
rDATE
BY
DATE FINALED
INSPECTOR
_t ,
a
�A
�r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
r BUILDING
APPROVALS
MECHANICAL APPROVALS '
Set Backs
6
Underground Ducts
Forms & Footings
I I 1.9411
Ducts
Slab Grade
aReturn
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
g 7
F.A.U.
Framing
V
Compressor
Insulation
_ _ _ f,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
0
Final
Final
BLOCKWALL A PROVALS
Sted6
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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:
i
Certificate of Occupancy
City of La Qui,nta
Buildingand 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:
Use Classification: SFD
Occupancy Group: R 1
56-600 JACK NICKLAUS
Bldg. Permit No.: 9709-088
Type of Construction: VN Land Use Zone: RL
Owner of Building: KSL LAND II Address: 56-140 PGA BLVD.
City: LA. QUINTA, CA 92253
-y: STEVE TRAXEL
Date: 4-10-98
Building Official
POST IN A CONSPICUOUS PLACE
Ism
— Em Me 9 1 Ng
REGISTERED INSPECTOR'S WEEKLY REPORT
JON 'I C,4
o"INIZA
V 12
3550 Condalia Ave.
Yucca Vallji►!'#n2
(760) 365.5045 7Y
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE X STRUCT. STEEL ASSEMBLY O �Y�OjQ
O POST TENSIONED CONCRETE ❑ ASPHALT *OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING /�
JOB LOCATIO
3-6-600 Jq
A✓1 a11441.5
A?7
REPORT SEQUENCE NO.
TYPE OF STRUCTURE/1 /,-07-PERMIT
DATE OF REPORT
NO.
NUMBER
AT/ - �!� DAY OF WEEK
/!
7
MATERI L DESCRIPTION
-3!o A�oo
ARCHITECT
IN PECTOR HRS. CHARGED
ENGINEER
ASSISTANTS HRS. CHARGED
INSPECTION GENERAL SUB
DATE CONTRACTOR €Vl, CONTRACTOR
/r
COPY SENT TO CLIEN Lo
CO INUED ON
PAGE OF
I
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE 3EST 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.
SIGNATURE OF REGISTERED IN
CTOR
A?7
v
a 75.
DATE OF REPORT
REGIs1rfR
NUMBER