9707-017 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby. affiR' i under penalty of perjurythat 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
134281
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.
(v,) 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. 4 • '
(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' compensatiomprgvisions of Section 3.700 of the Labor
Code, I shat forthwith comply with those provisions
Date: q 1 j Applicant - -
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 37.06
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.t
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 vol&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"Cate.
urposes.
Signature (Owner/Agent) j k"' .
. BUILDING PERMIT PERMT# °°NTR°`#
I 97417_017 54°77 .
DATE / � VALUATION 9s � LOT �' TRACT 29340-1
// �
JOB SITE
ADDRESS 5&756, JACK NIC10,AUS
APN
T(1-SSOYf11A
'OWNER
CONTRACTOR / DESIGNER / ENGINEER
ISL LAND 11 CORP
KSL DEVELOPMENT COM
X140 POA RIN6
$6140 PGA AIND 1
LA QUINTA CA 32253
LA QU1NTA CA 32253 =,
(-160r,71-3642 CBI.,# 4676
USE OF PERMIT
SFD
SPO, LOT i0»AYDR.,11.A.N'lA-
PLAN 04ECk:'FIFE, MVCME *BY?_", _",, FOP, kITJIMPLE I.SS'UF OF SANS
PLAN InTE
CW€ fON4 t; ON;ti` RUC`I'1OV 2,,101.(11) SP
P0RCHIP All 2.19),00 Sr!
G RAGE/C.ARPORT 6,36,111) Sly
PERMITFEE SUMMARY
f, CYN13t1213_"J0NFB 101-000.418-M $919.50
PLAN CRECK'F•' E 101-01711-433-.318 $180-74
I JECHA1LRCAC. F89 .11.01.000.41,",1-000 $79,00
IF-EC-MCAL MM, 1014104,10-000 $143,76
1y]<[IIVtPtNf;, t't 101.000419-000
STONGN OTIONFU -.ti1 SiI? 101 -000 -241 -OW
YRAD-NQ.FEE 101.-:0004237000 $20.04
Weit ,VfR[1/C t URE F 225-000-"3-342 $1_90.00
.�
ART IN PUBLIC.C+1',ACES - IWISIM 10.1-f1Q9455-0011
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SU � TAL CONS'tRL3C:MNA1+D PLAN CREi,.K
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A��, p 1.1997 TOT.&I,11ERA T FEES 1 UENOW
RECEIPTDATE
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DATE FINALED
INSPECTOR
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
Exhaust Fans
O.K to Wrap /
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
DryVall - Int. Lath
Final
Final -
POOLS - SPAS
BLOCKWALL A PROVALS
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
COMMENTS:
Final
Utility Notice (Gas) 1 3
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
Temp. Use of Power
Final 42 6e:
Utility Notice (Perm)
L;erriricare or occupancy
City of La Quinta
Building and Safety Department OF,.,t
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
Owner of Building: KSL LAND II
56-755 JACK NICKLAUS
Bldg. Permit No.: 9707-017
Type of Construction: VN Land Use Zone: RL
Building Official
Address: 56-140 PGA BLVD.
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
Date: 3-9-98 -.
POST IN A CONSPICUOUS PLACE