0010-286 (SFD)(V W
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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
"t
7803413
Date J11^ Signature of Contractor .��"� �-�•-- �GerF ,�
OWNER -BUILDER DECLARATION
I hereby affirm under<.penalty of perjury that I am exempt from the Contractor's
License Law for the4iollowing 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 t
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
(.er 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 p,r Policy No.
(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
Code, I shall forthwith comply with -the provision;., f
Date: ��py1 r < Applicant zOf
. 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 & 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 property for inspection purposes.
e
Signature (Owner/Agent) t ~• { �'Dates
BUILDING PERMIT PERMIT#
DATE VALUATION LOT`' p•,�? TRACT
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0.1117 22147
JOB SITE
ADDRESS
OWNER """
CONTRACTOR / DESIGNER / ENGINEER
WRIOP 'PAEaWER.; 1, Ukl
C#'f w 1,,w6kIL 0.ON91T'+:fJ,C' TOA3 CORP.
57 '*A
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Lh wiUINfA CA 92253
LAQUDITA C>& 92253
(766 R,15c .91.38' C'BIX '1516
USE OF PERMIT
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RECEIPT
DATE
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1BY
TE71
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings �/L
�� _
Ducts
Slab Grade �
�_ /�-
Return Air
Steel
Roof Deck
_
_
Q�Z/ /
Combustion Air
Exhaust Fans
O.K. to Wrap
_ _
F.A.U.
Framing
Insulation
�yl _
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
rDrywall - Int. Lath
0/
Final
_
Final
POOLS - SPAS
'BLOCKWALL APPROVA@,S
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
Waste Lines
_
/��/� s
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_
Pool Cover
Sewer Connection
KHN/ != e
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)
Certificate of 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:
57-605 BLACK DIAMOND
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction:
Owner of Building: WEISKOPF PARTNERS I, LLC
Building Official
Bldg. Permit No.: 0010-286
VN Land Use Zone: RL
Address: 55-161 SOUTHERN HILLS
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR.
Date: 10/15/01
POST IN A CONSPICUOUS PLACE