9709-097 (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 # rrLic. Class Exp. Date
yCC
DateSi � �/ �nature of Contractof
�g �
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
pe ormance of the work for which this permit is issued.
(N) 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_ WC WN1.11110015
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that insthe 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
woFkers' compensation laws of California, and agree that if I should become
'bject to the workers' compensatlon,provisions of Section 3700 of the Labor
Code, I h I o w. h com I with,�hlos"e oVls�'ons.
Date: Applicant-
7
pplip nt -•LiiV . d 7r
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.
J1. Each person upon whose behalf this application is made & eacfi 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
tJ�e above-mentioned property^for inspection pu nooses. F
Signature (Owner/Agent) / 4U_&1 W A'7 Date
PERMIT # CONTROL #
BUILDING PERMIT 9709.097 S 947
DATE}� G VALUATION $1.79,192,Sf'f. LOT 43 TRACT �ti 3 -10 -
JOB SITE
ESS wr14►-�47li�. ids �II�EY.k°..4 it� �
APN 61-555-04
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i,`cSS •�'#,if-\'f!
1)r}j. �.,y i -!!J f!
{?E''9' I�t!If?t /`Rf1A i(PiT j"lJ''�Fi51
t�l,].ti L)!1 O R�i,rlJl •. 61,�I.J l i.%ll�,.E
:3f5 -i liu 41116A, W. `t.,1.
5M- 0 PGA .BLVD
LA..QUIN 'A, (�A. 992253
l:tiQl,3I I -A. CA 92251
(Alft 11676
USE OF PERMIT
; ib
01) - `►�.,T�.IYi.,� MAN ifs, LOT ;S. Kt1N E',i6 :�t�.t'Jii k i�r� OF 37M.5
411100C.40 14 Ir 731110 Kit41L71)JUt'T Lki 1115SU; Utz MAI19li PLAN '1'VPE�
C,;C-;aTi:r?4 CONSTRUCTION i.W.00:N'
PORCIDA�A:rl() 110.00 $F
Q.A1te4c 1FJCA.i<$'Q'tZT 6,16 .04) 3
..�.'iei:Q 1, 2-6141TUS "US U O.�.� �4..�a,� W a tl*':. U10%
:4U1
- i i��'.wi. ✓,�..°'.#i
yy, y �.+ y;5 r g ,Cg �p ,g.
Ct N.X,F3IXTION!ITE8 101 -MO -41"W s9a�.�iy
.PIAN �',H CX rb'R 161.0rY)-4-)Q. -t8, ?n
W)C IANICAL FM toll-Oi(1.424-000 S791001
ifri s0"I`3dd'G N, tit '101 -WO -420 -Wo $ldJ.;ii y
I'E.LfIttI33Ti�30 ti 101-M-41MM $367..:!S
M"340- M!`i'€'ION VE`S - !A8110 101-OW241.000 $ Y11132
CRADIINC FU 101-000-423.000 s2o.00
i't � Ati t ld�IC;"si7�2 s 21.x-0€ -443-342 13,963106
ART A-N'P(TBLJ C`PLikfX3.ltl�:�il�'✓.0�,()fltf-.2�,�.>7(TC3 �l�S�'I
1•
3 -i, k Z�i2�i ±, t34 Ili i i1ND PLAI ? CHECK
��,�`? ].I S
PA'a
S W, ME-PAV -13
SEP 26 1997 TOTA :. PERAI) T F.IEas O(F,l NOW.
5
! 1
RECEIPT , r,
DATE p,
f BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs p
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade 4 UReturn
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing _a ff
Compressor
Insulation —Q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath '
O
Final
Final — i -
BLOCKWALL APPROVALS
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 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
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. ,
Smoke Detectors
Temp. Use of Power
.-Final
Utility Notice (Perm) Ti
COMMENTS:
REGISTERED INSPECTOR'S WEEKLY REPORT
1.J c/, y
JON TAN DY �tA oojjv- '4'a
3580 Conda Ave �� 2 R�Cp
Yucca Valley, ,44.
tvb
(760) 365-5045 ���
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY O FIRE PROOFING
❑
�j( OTHER
W �/
JOB LOCATION
,5 -8 7D
REPORT SEQUENCE NO.
TYPE OF STRUCTURE
PERMIT NO.
D!}TE
DAY OF WEEK
MATERIAL DESCRIPTION
}'
Q
ARCHITECT
IINNNSSPECTOR
J
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
,GENERAL lelc C SUB
CONTRACTOR/ v , CONTRACTOR
Pi S ,
/ A,-
11
/0 2,0 g
/0/2,0k-7
3 x
}
I.
4:1-
i
f:
ll
r
•
COPY SENT TO CLIENT
ONTINUED ON NEXT PAGE O
PAGE
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 REGISTER NSPECTOR
//-10- f7
DATE OF REPORT REGISTER NUMBER
Certificate of Occupancy Vol�.
City of La.Quinta
Building and Safety Department OF,�E°`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:
Use Classification: SFD
Occupancy Group: R 1
Owner of Building: KSL LAND II
56-870 JACK NICKLAUS
Type of Construction:
Building Official
Bldg. Permit No.: 9709-097
Land Use Zone: RL
Address: 56-140 PGA BLVD.
City: LA QUINTA, CA 92253
By: STEVE TRAXEL _
Date: 5-12-98
POST IN A CONSPICUOUS PLACE