9707-015 (SFD)LICENSED CONTRACTOR DECLARATION
lirereby 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
f .7(34%9"9 `RT t , t X1341. 5
Date{ ,h t/ � Signature of Contractor ` '/:' Z
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).
O 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.
(�() 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.
WR,T.CH n4S. CO. WC 61749005
(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' compensation provisions of Section"3 00 ofth-e 'Labor
/Code, I shall f rthwith comply with those rov ions.
�1 Date: ` Applicants A
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 restriction s'set -forth: ons 14
application. r
1. Each person upon whose behalf this application is made & each person at
il
whose request and for whose benefit work is performed under or pursuant to:1
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 purposes.
/Signature (Owner/Agent)Al
BUILDING PERMIT PERMIT# CONTROL#
91#7_015$4475
DATE VALUATION LOT, TRACT :
% ��a4,443,'lii ' �
JOB SITE
ADDRESS ,,G g� �S .�t�t:K N1C,.i ",J.T,,43 '
APN
76.1 -.",*009
OWNER
CONTRACTOR /DESIGNER /ENGINEER _
I`SL LAND li G'41ZY
CEfEtC
56IX0 PGA ID
- 140 ..PGA 81.,V0
LA Qym.k CA x`53
LA t?UTNTA CA 92253
(760)771-3642 CBLff, 4676
USE OF PERMIT
SFIQ
Wi), LOT 8 - 3A, .
PLAN CHECK ,FEB IRlIDLIC.✓l D BY 75%FOR ANfIJT TI[PLFs ISSUE fOF SAME
PLAN 11711,
CUS"COM CO STPIUC'W14 2,450.00 SF
KT< I PA:T1O 245.00 SF
GARA VCARPORT 527.00 S,r
ice`!if �'1'Ia C(3 i'a't3f'CgNS'�'l2UL'1lt�N
20,441.10
i'EEtN` T put E SI(T1 I%4Ry
CONrS`t RUC'.i`' ON FW_, )01-00"1"00
P1<AN CHECK M 1101-000433-315
K, iCI�,'1.1�ICA _F 101-000-121X000
E1,E'C.M1CAL FFF" .101.000 X20-000 W53.7)
PLUNMINc FEE 1.01-000-419-000 9167.25
'STONG 4-10TIO M, - RE= 101-1.0-241--040 $20.44
ORAialNG PMi 14 t -000.423-M 37,0°Ofl
,
ttr'R7sSTt�C'ti�fy31 t'm. 34,'526.64
AtL't' 'tf•(1'U�t.i<Gi?G,ACiv • i'� �t31-1�(�="?55000 4rc>l, l !
r
a7
; tJ -TIAL CONS'11t:UCTION AND PLAN C;IEC K
y
S6,454.0
S PRS PAID CIES
$00)
AUG 01 1997.. TOTAL PERMIT TEES DUE NOW
$6,454.05
y
rRECEIPT
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 A
Return Air
Steel
Combustion Air
Roof Deck 9
Exhaust Fans
CK to Wrap
F.A.U.
FramingCompressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 7,
Drywall - Int. Lath #7
Final
Final LZ7—qs-
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg, Test
Final I
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)
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) Zal
Certificate of Occupancy I ,
City-ofLaQuinta � �g
Building and Safety Department OF.E
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: 56-815 JACK NICKLAUS _
Use Classification: SFD Bldg. Permit No.: 9707-015
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 TRAXEL '
Date:
2-23-98
POST IN A CONSPICUOUS PLACE