0204-212 (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
763IS7 o5m 1/2U
,✓
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.
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 Mfl)HMS. Co. Policy No. Z4423044
(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: r' X. Applicant ri Aas rig °�M
—Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this:applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. x
Signature (Owner/Agent) /��;y --, Date �`:✓`���*
c
BUILDING PERMIT PERMIT#
DATE VALUATION 020,79&69 LOT 4A' TRACT 2&I"
u
JOB SITE a
ADDRESS lie.$]0 itNl0£al (JP#
APN
742-1604)11
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C;A.R5"f ONES GOLY W'itiST, U.tu
JS omm SE.if?mC in, G'omm•um"ng,� xNe
200 2. WASWNCUON AVE.
200 L WASW- NO'jf.V"M AVE,. #100
ESCONDM CA 92M5
ESCO1v1'?;;.DO CA 92025
Mlh 5413
USE OF PERMIT
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Cir'�.C�3C"A�3'+0;�,7• '���.� orf
(XW.11'1V..V(1.3t:d0N mfr, 1tf 4X)D- i.fi&-W $1,413.00
;Pi:a�i7d,�SC`�ll?YE t+Da-OW439-318 51,145,51
ril?f;E dLC.A1.,1 1C141W1t2I-" $111 xv
P.XJ.R05MVIm 101 -M -449 -OW $20535
MONO MOTT N RE - RIOD 101.>=W-24.1: 000 $32.09
,AY t-1 FM 101-OM423.000 col)
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�:TX1A/i)�F.]�4n1/��3�9 ��9(Y(�
J� er m �C eJ'.ae.48. PI.ACRS " XS�YXlr, fit, 0 I00-,i�•B.J^CJUY,iI .•!$].I..7P�
p U88 PRE FFEP
# -PAID
.Ofl
.i lllL'L
CITY0FI,AQUINTA
FINANCI* DEPT.
RECEIPT
DATE
BY`.:
DAyE F L D �IrOR
7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
A
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
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
02
Drywall - Int. Latth
Final
Final tJ
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 APPR VALS
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
Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
61T/:1,612�
/` _ / /
11
Certificate of Occupancy
Tjhf 4 4 a"
Building & Safety Department
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: 80-810 WEISKOPF
Use classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3
Type of Construction: VN
Owner of Building: CAPSTONES GOLF WEST, LLC
Building Official
T IN A CONSPIC
Building Permit No.: 0204-212
Land Use Zone: RL
Address: 200 E. WASHINGTON AVE
City, ST, ZIP: ESCONDIDO, CA 92025
By: Daniel P. Crawford Jr.
Date: 6/24/03