9707-019 (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
(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.
(tit) 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.
.LLIR,,Ie.`H,IFf3 C_0.w�Cs38�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
subject to the workers' compensati no provisions of Sept'IT-5700 'of the Labor
Code, I s all f - rthwith comply with tho .e/provision .
Dater , Applicant
Warning: Failure to secure Workers' Compensation coverage Is unlaa 01 and
shall subject an employer to criminal penalties and civil fines up to.$100�000, in
addition to the cost of compensation, damages as provided for in Section 3706 .
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions'.' and restrictions -set,, forth on his
application.
1. Each person.upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or'pursuarit.to
any permit issued as a result of this appliCaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void if ,
work is not commenced within 180 days from date' of issuance ,of such
permit, or cessation of work for 980 days will subject permit to cancellation.,
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws. relating to the building
construction, and hereby -authorize representatives of this City to enter upon .
the above-mentioned property for inspection purpos Sk.
_4 R �r 0Signature (Owner/Age tn) a ` ate }
°`#
_ BUILDING PERMIT PERM T# °°"TR5479
4707-019 J 4 7 9
DATE VALUATION LOT TRACT
.1." . . y 2 281,16-'1
JOB SITE
ADDRESS .56-685 JACK NICK .AVS
APN
16t-SWO1 3
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KS:L:4rANn 1.1 CORP.KSL
C0'
CDEVCLf71 MEh"f1.1
-50140 PGA 131M)
56140 PGA .RM
LA QTANTA CA. 92:25 ►
LIV QUINTA CA 02253
(7601771.3642 Ci. O .1676
USE OF PERMIT
Sl�l►
SPI). T.Oil' '!:' , IMMA A �1'.l AN 2A.
PLAN CHECK FEE REMW ED BY 75% FOR MIAMPLE ISSUE OF SAME
P1,Akd 11VE.
CUS'i`OM't�
ClNST':TttJC'7'12 .ON 479�.etc)� %P
P012PATIO, 202,1 M )[•
aAR01c7i.,fC.A.RI)OR'_T - 622,00 SF
ENICIMa S ;lt Ill Of C-ONYMCbtUCION
2001101.90
PElNOT FEE SUMMARY
CONSTRUC.1'.iON FEE 101-000.118-000 599100
[ALAN CHECK F95 101-000- 39-3i$ $204,06
Nfil; RAOiICAL PERf31=u0i� i-f�Clt) 9; ,
ELF0 tie g1 F P -E, 101-000420-000 $151.2t.
PT trr SNC FIT 101-000-40.000 $173-2
S 1'ONWA4 d l`.1ON .'WIV 101-000-241-000
OPAMING:FEE. 401-000-42:3-000
1[�tt�EA'S'i'E,lECI i 'l E<ki 225-000-443.342 $4,444.'69
Al+; iA1P�'[3T:iCF�1,ACI S» R1rtS3i^ 101.-00015 000 $2.50.30
i
(�TAL_CONSTRUCTION AND CHECK
S6,356.63
� ,PLAN
LASS P1'ia~-PA1�4) %F LS
S0,00
AUG 0.1 1.997
TOTAL. PEIRIM - PE. ES 01.1U NOW
$6.356:6:s
4yT
RECEIPT
DATE >
BY/
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings A
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Root Deck lj
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L. 4
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final -17—
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS 4
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 44 IW.6aPool
Cover
Sewer Connection 14171171
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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) Cj
COMMENTS:
r+
M
Gertiticate of occupancy
City of La QuintaMe -
Building and Safety Department afnt
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: R3
Owner of Building: KSL LAND II
56-685 JACK NICKLAUS
Bldg. Permit No.: 9707-019
Type of Construction: VN Land Use Zone: RL
Building Official
Address: 56-140 PGA BLVD
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
_ Date: -- 2-17-98
POST IN A CONSPICUOUS PLACE