9709-091 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby aNirm under penalty of perjury that I am licensed under provisions of
diapter 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
714281---�., ti l 1iq.)
v Date � 7Si nature of Contractor-" �wf lJ6
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&RC. 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 l9 �y Co.icy No. IMC r « .
�I.le�i{r:1i11,111.3. litio:',ul. f;,r,.'�ii$rfyg
(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
ubject to the workers' compensation provisions of -Section 3700 of the Labor
4ode, I.sf9rt rv' comply with t•ho� provisio J'
ate: �`_' /Applicant Ak"�
Warning: Failure to secure Workers' Compensation coverage is unlW ful and
shall subject an employer io criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each personatT
--
" whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. o
2. Any permit issued as a result of this application becomes null and void'if
work is not commenced within 180 days from date of issuance of such,
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby -authorize representatives of this City to enter upon
/S:,gnaturee above-mentioned property for inspetion purposer! (Owner/Agent); Date 4 �`
,r� J
CONTROL'#S`- •:
PERMIT #
BUILDING PERMIT
DATE t� VALUATION �,?3�$g11"�. �� LOT �{'f TRACT
Ij
JOB SITE
ADDRESS :�:s-{D�1 `l �V�:1t
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Ks.i. m7 u, _)l�k�°1iaY�:"1' CriJ1�P
5-140 hurt. BLVD, D,
i59 U P61 A BLVD
TA QUINTA, CA, 02253
LA QiL Its'' A CA. 4225:3
C TIM! 4676
USE OF PERMIT
STM -IM, PLANi� 110031.
iia f't7, i W'%s'af�i' KI�"1'7 1i}_ 00 SI
iO V10-00 NP
. 61n�(i+TBiilq•�,ak :v COST��P a.*5}l'VSI irUC�.%OIN
.1J{✓�,.¢9.�..50
APOW-UPAT
J?LAN r -c -'K � 1%.;! E 1014i€!(f-4393 3118
i'f` CTi Vv 101.,00(1-:�tl8-TW_ c fir. r f
i�ii.>l:y3�t31i 3'�L:fS1.-ha •,Si.G2Y'171a1P %t //�.ii%
€;,f.1%.�""3 O.l L VIM 101.td {�>�3t3Nfa�i0
S'y�y1014O'y�l;�+ty��TFON M-R3:S1t)
9101-/i��C-2,491-/0[00 axgl��n�,
15— 0-443�r344�2g 3,!�c0.0+)
' lip 215-00-443r341
FF[iSi T y A
#Vl T W l�Cff9i,l+vR LMLES Pk'e:,Zi f0S-0010'•25 7^�1`J'k1' � S110 98
ART
�}��d�A'.«.1 illis!'d �4i`EI TJ ON AND P l: kiv i ���yCk
'-TWD
56,26 . 4(1
LESS .��.� ID FEB
�U.t3i►
Q fo TO- SAT," PERM T FECN I'MRI NW11V .
S6,2 3.36
J: A
RECE P -V -
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—,7
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
Final
Final
BLOCKWALL APPROVALS
steel
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 W'
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
f:
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
—/D -
Appliances
Final
Final
Utility Notice (Gas) /S
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:
f
Certificate of Occupancy
City of La QuintaOW
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: 56-690 JACK NICKLAUS
Use Classification: SFD Bldg. Permit No.: 9709-091
Occupancy Group: R 1 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: STEVE TRAXEL
`Date: 4-15-98 - - -- - - _
Bu.ilding Official
POST IN A CONSPICUOUS PLACE
4
REGISTERED INSPECTOR'S WEEKLY REPORT
C/�' o'k
JON 16NMtz,
3580 Condalia��"i4vq, RF�O
Yucca Valley, CA 922W46F!�
(760) 365-5045.
TYPE OF
INSPECTION
PERFORMED
❑REINFORCED CONCRETE STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ �� Q
OTHER
JOB LOCATIONA
T'�
REPORT SEQUENCE NO.
TYPE OF STRUCTURE
�CoT .37
PERMIT N0.
DATE
/ - f 7
DAY OF WEEK
MATERIAL SCRIPTION
ARCHITECT
INSPECTOR
HRS. CHARGED
ENGINEER
ASSISTANTS 0
HRS. CHARGED
INSPECTION GENERAL n`
DATE CONTRACTOR V'�
SUB
CONTRACTOR S
ji5-, . di AM
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of ale,
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1
COPY SENT TO CLIENT
CONTPUAtZON NEXT PAGE ❑
PAGE OF
I
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BES- OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OT'iERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS, SPECIFICATIONS. AND APPLICABLE SECTIONS -OF THE
GOVERNING BUILDING LAWS.
SI ATURE OF REGISTEREIN ECTOR
97 6
DATE OF REPORT REGISTER NUMBER