9709-096 (SFD)t _ _
LICENSED CONTRACTOR DECLARATION
I IT�treby affirm under penalty of perjury that I am licensed under provisions of
•Ghaptdt 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
134263
Date / -pignature 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.
��//11 I have and will maintain workers' compensation insurance, as required by
S ction 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. We
(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
ubject to the workers' compensation provisions of Section 3700 of the Labor
fCode, I shall forthwith comply with those provisions. �_11
Date: �./�'7Applicant --• � J D
.r`A _f . r- y
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his.
application.
1. Each person upon whose behalf,this application is made R each person at ~
-whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify `
& hold harmless the City of La Quinta, its officers, agents and employees �
2. Any permit issued as a result of this application becomes null and void•If.
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pgropertyfor inspection purpose��s.
/Signature (Owner/Agent) ?r 3� , z, A - ate < 'd�
r71
-BUILDING PERMIT PERMIT# CONTROL#
t:s (d) 46
DATE �%I VALUATION21ffl.dy3; �� LOT ;,� TRACT
JOB SITS :�6i 1►f� dFA�rli�lx`V
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
L A 141 riS, 1,51.. vrl'.
XXOZO .0
I,AQ41f7"iA CIA 912253
IAQlrilV1A CA.
USE OF PERMIT �.
SFU
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1,1.i:5✓ il.d .#.' I.1•`iV �r[4MIASPpE Mhfit PLAN TYPE,'
t;t_=`�a i f�i4a � Latti'��'.t_Rii�•;"1:"i�N "0.:37 9 r.ttst 3.I7
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i"O 3'E,114.! CA"I"*1
PERMIT FEE is "A INIARY
1r_'0b! tT1CT.10N 1-1M 101A)00-41 R -OW ��l100
t,AN 74ift`KP'f;.L';
E', UiCnlb:CAL it EE ? �''t yUi")��$�U-Q{�) $! �� 'Z i
3'i.V,IMIONUFEE S173 »5
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CiRt1VfVG ;6U3 101-1000-42"i—M $20.00
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ESS PMOFFE4
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$6,356.43
RECEIPT r
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
.� OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Sbt Backs
7 ,
Underground Ducts
Forms & Footings
Ducts
Slab Grade
4Z
Return Air
Steel
Combustion Air
Roof Deck
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
_ Q
Drywall - Int. Lath
h 7
Final
Final —
BLOCKWALL APPROVALS
POOLS - SPAS
Sted6
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
d
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) / 4F x
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) I v-
COMMENTS:
,f
4 CITY OF LA OUINTA
i
I,
Pf 0 V 12 REC`® JON TAN DY
BUILDING ANfj SA' -03580 Condalia Ave.
ucca 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
❑ C,% vP i
A OTHER d�l�
e/lw I fvt
JOB LOCATIO/N,,//^^
` 0
,
4Z tA
REPORT SEQUENCE NO.
TYPE OF STRUCTUREPERMIT
NU.
DATE
/-*/,- f 7
DAY OF WEEK
MATERIAL DESCRIPTION
-
ob
ARCHITECT
INSPECTOR
T•' �N
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
Q' GENERAL
CONTRACTOR L
SUB
CONTRACTOR P, S We / �/
qi
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COPY SENT TO CLIENT
TINUED 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.
SIGNATURE OF REGISTERE I SPECTOR
z
DATE OF REPORT REGISTER NUMBER
r
Certificate o.f 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 in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 56-840 JACK NICKLAUS
Use Classification: SFD Bldg. Permit No.: 9709-096
Occupancy Group: R 1 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 92253
By: STEVE TRAXEL
Date: 5-12-98
POST IN A CONSPICUOUS PLACE
Certificate o.f 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 in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 56-840 JACK NICKLAUS
Use Classification: SFD Bldg. Permit No.: 9709-096
Occupancy Group: R 1 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 92253
By: STEVE TRAXEL
Date: 5-12-98
POST IN A CONSPICUOUS PLACE