0208-143 (SFD)'LICENSED CONTRACTOR DECLARATION
yl 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
Date f Signature of Contractor
OWN ER-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). -
( ) 1, 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.
( ) 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 9XIMPT 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'those provisions.
Date:`/..,pr Applicant
Warning: Failure to secure�orkers' 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 td
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) '� ^�' _. Date° `<"
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
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JOB SITE
ADDRESS
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OWNER
CONTRACTOR /DESIGNER / EN INFER
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BOX 366
.T.A �)UINT k. C�i. 92233
LA QiJUMA LA 92253'
("i'E+t3�S�4a4E�:�2 Cr'iF 323e
USE OF PERMIT
SM) - LOT 117 PLA 14 38—PERMIT IT IDES NOT 1-NCLUD--'t~ 11IrC?C X WAI_,IA
P004 SPA OR DRIVEWAY APPROACH
C US"I0M CON S7RUCT'1UNJ 0,13,00 O
PORCI• IP.A` IO 90&63 SP
c. AR.AMUMPORT MIA* 1114F
awr=A= con cep gaffs ttm
407,IX110
PIER ST FRE €ii7 �+l, tib •..
Cr014STRUCTI0N PER 101,000-418-M SIM7.59
PLAN CHECK ME '101-060-439-318 .S1,285.3.5
1E 101-000-421-OW
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a�
y�NT�t,i�1��I
N121'IC,AL ME/�; w
ffLUMA3I; OFe.L'+ 101.000-419.000 $153.75
S1170NO MarIaON lti'1EE � MID 1011-000-241-000 $40.71
ORA.T)NO F'E'E 101.000.4123.000 $15100
OM.t f3PAR IMPACT FEE 00
ART M. PUBLIC PLAC- RESIE 270-000.44.5,-001 $517,63
"sLww1AL cdimiR TC''noN AND PY.Am C:1my,
$6,710.54
$1100
Q
A. YERMr 11:S DM now
Qiir, � � 2002 • . -
CIYY OF LAQUINTA
FINANCEDEPT
RECEIPT
DATE =
BY
DATE INAL
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
U de ground Ducts
Forms & Footings
u s
Slab Grade'Return
Air
Steel
Combustion Air
Roof Deck
„� _
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation2
L
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
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Eo_ RC YND_312
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Qp 2
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�t> �6�{'%�O/L !/jil"W4
!�� /,S�
/" Y
.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALSTemp.
Power 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 ocs
Utility Notice (Perm) H
Cert� icato ofoccupancy..
7 G>
o44
f9ti Buildin - & =Safet De artment
g Y p
This Certificate -is issued pursuant to the requirements of Section 109 of the California Building ,
Code, certifying that; at the time of -issuance, this structure was - in compliance with the
provisions of the Building Code and. -the various ordinances of the City regulating building
"construction and/or use: -
BUILDING ADDRESS: 81-135 Shinnecock'Hills .
Use classification: Single Family Dwelling 'Building Permit No.:.0208-143
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: Weiskopf Partners I, LLC ;' Address: 51-161 Southern Hills
City; ST, ZIP: La Quinta, CA 92253
By: Daniel P. Crawford Jr.
Date- 7/30/03 .
Building Official -
POST IN A CONSPICUOUS PLACE `