9709-095 (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
� Ni4-I
"/Date ` Si nature of Contractor
� 7 g �1
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.
•((A 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.
=Mcli R411111CC", WC fkr, =2505
(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
Abject to the workers' compensation provisions of Sectio 3700 of the Labor
Code, I'MI fort wit comply with those pro isi ns.
/Code,
�� 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 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"fo'rth-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 Xis
& 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
tt{ above-mentioned property for iin}spection`purp�oosses
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Signature (Owner/Agent) 11� f Date
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BUILDING PERMIT PERMIS'#'
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DATE VALUATION ; €yds, f� t LOT 41 TRACT 28,001
JOB SITE
ADDRESS1i til .4�.1..i.�a,..e�JRi
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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LAQ JPi , l! CA 92253
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USE OF PERMIT
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CCAA:a:MIJ FIX, 141-0004,134J00
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F8,13S DOE NOW
CX. . .
RECEIPT
DATE
BY
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 g" 7
Exhaust Fans
O.K. to Wrap _G _
F.A.U.
Framing —/s`.Q
Compressor
Insulation / -,o —
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 AP ROVALS
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 Plastery:.
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) IS77 t( i
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
IlFinal
'aUtility Notice (Perm) ,�
COMMENTS:
OF LA OUINTA
s ON TANDY
NOV 12 RECD 11
3580 Condalia Ave.
R R - SAFY66ca Valley, CA 92284
L INSPECTION'SERVIC-C (760) 365-5045
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
I
❑ REINFORCED CONCRETE X STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY O FIRE PROOFING
O /)
OTHER f M
W i0f I rL/
JOB"ATION
/ �
i
REPORT SEOUENCE NO.
TYPE OF ST CTURE, O 7-
,q o
PERMIT N0.
11 6 - q �
DAV OF WEEK
MATERIAL DESCRIP{T/I_ON ,�y
V
ARCHITECT
INSPECTOR
J
HRS. CHARGED
c
ENGINEER
ASSISTANTS I
HRS. CHARGED
INSPECTION
DATE
GENCONTRACTOR Ks
SUB
CONTRACTOR /,oS.
^
�e,141
C
A
4
y
R
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE OF
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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!
SIGN,,F REPORT _/
TUBE OF REGIS�TERED N EC,T�R
11-4,
/ � _ 9
DATE OF REPORTOF REPORT
Certificate of Occupancy
City of La Qdinta
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:
Use Classification: SFD
Occupancy Group: R 1
Owner of Building: KSL LAND II
56-810 JACK NICKLAUS
Type of Construction:. VN
Building Official
Bldg. Permit No.: 9709-095
Land Use Zone: RL
Address: 56-140 PGA BLVD.
City: LA QUINTA, CA 92253
;By: STEVE TRAXEL
Date: 5-11-98
POST IN A CONSPICUOUS PLACE