9709-098 (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
313 J
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.
W 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 NQ.
(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 3700 of the Labor
bode, I sha I fortwith comply with those provisions. --
Date: :! jAppIicant
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. --t-1.1.
1
1. Each person uNun'whose behalf this al5�lication 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
correc!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
th above-mentionedeproperl for. inspection purposes.
Signature (Owner/Agent) Al -'Date 7
BUILDING PERMIT PERMIT# CONTROLoo#®® Q
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DATE VALUATION; l�i;. -ET LOT { I TRACT
JOB SITE�y{� a1�1..[\ n1�kl�
APN �tl=-TU�Zitiilf
ADDRESS .1.l
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�'.St,1.r1�jk) tl 1
hS'::.:��:i'il.>`',i�1iL�i'"!'!'t�L'3.ttii•'
56 40 i. BLVD. ,
5.151120 PGA PIL O
LAi:;j1134+jTA CA 9?25
I..P,O�,11tv'M (.A 92253
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USE OF PERMIT -
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LEM 10PRE-PAIDIT -S
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SEP -2 6 1997
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
or
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
Exhaust Fans
O.K. to Wrap
— -
F.A.U.
Framing
•> 3 - FY
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 — (2,— -
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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
42zzeHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
1APool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) �Z
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 "
11Utility Notice (Perm) T09-
COMMENTS:
REGISTERED INSPECTOR'S WEEKLY REPORT
t
JON T D //,, r
3550 CondalkVe.., CQ
Yucca Valley, CA 922- SSI`
(760) 365-5045 �y
TYPE OF
INSPECTION
PERFORMED
p
❑ REINFORCED CONCRETE STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ Sjy�
,XOTHER ��iLL �`
JOB LOCATION
(/o- TIo
/
REPORT SEQUENCE NO.
TYPE OF STRUCTURE`
-A
PERMIT NO.
DATE
`/ -
11-41- �'-7
DAY OF WEEK
MAT RIAL DESCRIPTION
MA
ARCHITECT
INSPECTOR
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR
SUB
CONTRACTOR '
J
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COPY SENT TO CLIENT O
CO D ON NEXT PAGE 0PAGE
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. 1 HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
& _ - C4/
-
SIGNATURE OF REGISTERED I PECTOR
DATE OF REPORT REGISTER NUMBER
Mr A
Certificate of Occupancy
City of La Quinta g
Q
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
56-900' JACK NICKLAUS
Bldg. Permit No.: 9709-098
Type of. Construction: VN Land Use Zone: RL
Building Official
Address: 56-140 PGA BLVD.
City: LA QUINTA, CA 92253
_ By: STEVE TRAXEL
Date: 5-12-98
POST IN A CONSPICUOUS PLACE