0204-213 (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
Date Signature �3� Signature of Contractor fz-�
r f ' 6
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 exclusiLely'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 1"TH #NS. CO. Policy No. 94506
(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 sh�fort�h with comply with those"provisions. _
Date: 4,0%V Applicant /-�;O�XAV
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and -attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for •a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application -is made'& each person at.
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold Iharmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days.will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, a68-tState laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for✓nspection purposes.
Signature (Owner/Agent) �'� ,�r/i,!9p = Date .,
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` BUILDING- PERMIT PERMIT#
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DATE ., VALUATION . - LOT TRACT
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JOB SITE
ADDRESS � F� LNi B � f�
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OWNER
CONTRACTOR (DESIGNER f FIN61NEkER
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"CIONDMO CA, 92025
6-900NDMO 0,A _W AWS
(760)839-W_438 CULO 5413R
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USE OF PERMIT
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MAY 128OZ
CITY0F1,A QU11RfTA �
RE't?�t "°^ XT jl$y'
BY i
DATE F ALD
INSP T
ci
N,
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
Compressor
Insulation
f,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
/ 47
/8
� o
Final
Final
BLOCKWALL APPROVAL §'
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
Sewer Connection
_
���1A
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
3 —
Final
Final I
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:
A* ,.�
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S.i�i
Certificate of Occupancy
I•cawoRnTm��
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G� OFTYBuildin & Safet Department
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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: 80-820 WEISKOPF
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0204-213
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CAPSTONES GOLF WEST L.L.C. Address: 200 E. WASHINGTON AVE
City, ST, ZIP: ESCONDIDO, CA 92025
�d4, /4-tBy: Daniel P. Crawford Jr.
Date: 7/3/03
Building Official
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POST IN A CONSPICUOUS PLACE
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