9709-093 (SFD)4 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
h_;�Z/J)
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.
VV 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. AKC 61M,00051
(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
wprkers' compensation laws of California, and agree that if I should become
lubject to the workers' compensation provisions of Secfio 3700 of the Labor
ode, I **fol 'wit comply with those p�ro�Is�ion
dddddd Date: rr' y Applicant -
Warning:
J
Warning: Failure to secure Workers' Compensation coverage is LILL 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
tyle above-mentioned property for inspeccti1on pur oses. cy'
1!/Signature (Owner/Agent,, ate / �+ ,
BUILDING PERMIT PERM'T� 40APM CONTROL#
5943
DATE VALUATION $ 4)4,U2.74) LOT 0 TRACT
112. 4,11 1
JOB
ADDRESS :4.7!4; Jli'i.l; i'YA.:,.tiLM S
APN 761-550-4045
OWNER Y
CONTRACTOR / DESIGNER / ENGINEER
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
� W
71
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
2 Q-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
, 9
Drywall - Int. Lath
lf&inal
Final
— —
BLOCKWALL APPROVALS
POOLS - SPAS
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
:.:Smoke Detectors
i _Temp. Use of Power
FS
Final
Utility Notice (Perm) c
COMMENTS:
Certificate of Occupancy
City of La 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 incompliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 56-750 JACK NICKLAUS
Use Classification: SFD Bldg. Permit -No.: 9709-093
Occupancy Group: R 1 Type of Construction: VN Land Use Zone: RL
Owner of Building: KSL LAND 11
Building Official
Address: 56-140 PGA BLVD.
City: LA QUINTA, CA 92253
By: STEVE TRA:XEL
Date: 4-14-98
POST IN A CONSPICUOUS PLACE
%01Tr OF LA QUINT3 ON TAN DY
NOV 12 REC`0 3556 Condalia Ave.
�� �Y Ecaa Valley, CA 92284
(760) 365-5045,
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ SILO �J
X OTHER )i M'
�j / 4-1 !V
JOB LOCAJION��
A ,�
REPORT SEQUENCE NO.
TYPE OF STRUCTURE
PERMIT NO.
DATE
DAY OF WEEK
MATERIAL DESCRIPTION P
ARCHITECT
INSPECTOR
1
HRS. CHARGED
ENGINEER
ASSISTANTS
NRS. CHARGED
INSPECTION
DATE
GENERAL AJ 4 �� 1/1 I SUB � � .
CONTRACTORCONTRACTOR
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COPY SENT TO CLIENT
NUED ON NEXT PAGE ❑
PAGE OF
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.
j SIGNATURE OF REGISTERED 1 PECTOR
/4 -/_
DATE OF REPORT REGI ER NUMBER