9707-016 (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.
(y) 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.
zz RM14 MS. C0. we 644651)5
(This section need not be completed if the permit valuation is for $100.00 of 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
Code, I shall fo hwith comply with thoseoprovisions.
Date: 1 Applicant
Warning. Failure to secure Workers Compensation coverage is unlaw I and
shall subject an employer to criminal penalties and civil fines up to $1.00000, 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. 11
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 property for inspection urposes.- s
b Signature (Owner/Agent)_- y r+ Date," t.
1W .,
ERMIT# CONTROL"#BUILDING w`wMI� P
9707-016 54,76
DATE VALUATION LOT8 TRACT $204,442 70 9
JOB SITE
ADDRESS % 79.5 3A.CK NIC':.K14AUS
APN
761-550-010
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KSL 1, AND 11 CORP
1:..51, DEV CLpr%r,mr CQR:P
56 j 4O PC S. 'j3.uvb
36140 P&A BIND
LA. QUTA TA CA 922253
LA QUINTA. CA 92253
(7601171.3642 C13I,;t! 4676
USE OF PERMIT
Sim
9- }3. 1,00 9 - RYDER -01,AN A.
PLAN CHECK F EE RMUC'Ej3 BY 7YS FOR Mf lLTTPI.F ISSUE OF SANIF
PLAN TYPE—
YPE-til;fS'1OMCONS"1'ttil+;:fJON
CUSTOM CONSTRUCfJON2,450.00 SI
POR.G HIPATIO 243.00 3
OA.R.A OCARPOI2T 527.00 SF
1!,S°.��#�'[,�L'f ED CMT (fir` CONS!"i�� C110N
204,442.70
P1"r`?kMIT FRE SUMMARY
CONSTRUCTION FRE 141-000-4.18-000 $1,007.130
MAN CHEC.-K M 101.000-439-318 S?05.82
m 1 41C;r . lf}l^D t1-12.i-L�Oi� 592.110
1,--L C;1'.RJCAL tW .101--000420.000 S153.79
PI,f-iTv1fI1NO FEE 101-000419-000 $167.2.i
ST% 10MOTT+LNF' -:MID 101-000-241X0,00 . $40A4
GRADMIG FEE 101-000-423-.000 +$2ti o
.1WRAS1'R:t3t:'.1`URF,M 225-000-44MN2 $4,:26.64
."'i "tAlP SLICPt.ACES -PX- tc 701-000-255.000 �3F1.ti;
M;
3 v0N. YHECK
L COr- MUCCHECK
S> 1 Tt�TAF1AND PLAN
$� ,454,0S
AUG 0.1 1997
x+C1T AL PERMIT FL+'E.S� DUE NOW
S6,454.05
`R f t� + f
a
RECEIPT
DATE
BY i
DATE FINALED
INSPECTOR
I
C---- INSPECTION RECORD
t OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
14
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 vv
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 — 3 —
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
i 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 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)
COMMENTS:
Certificate of Occupancy
City of La Quinta
Building and Safety Department �°<Mo.mt°`s�
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: 56-795 JACK NICKLAUS
Use Classification: SFD Bldg. Permit No.: 9707-016
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: KSL LAND II
Building Official
Address:
56-140 PGA BLVD.
City:
LA QUINTA, CA
By.
STEVE TRACE'--. T
Date:
2-23-98
POST IN A CONSPICUOUS PLACE