0204-221 (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
'?ia31 �? k2 51� 1 X03
.r� � r T• � fry
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 ZENITH INS. CO, Policy No. 7-M,73945$
(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: ; ✓ f . t /f Applicant cl� r—, -1�
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.
A
Signature (Owner/Agent) // � ''✓ +�" .� Date Zl-XA-"
�l
._ BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
:I5 2W4
JOB SITEAPN
ADDRESS g "INIK0yp
1W24.1,10-Wa1
OWNER
CONTRACTOR / DESIGNER / EN (NEER
=01=00 CA 92025
XWONf ID0 CA 92077
('lf 0, 839�em -141, 5413
USE OF PERMIT
%0,TGLL..A!M, Y DWEMLDIG
. - I SOT 3." PLAN Ivy.. PERMIT 0093 NOT YNC;1.t3DE HLd3 K
WALIA 31004 s.PA OR DRIVEWAY APPROACH. 75% t1EDUCTIO14 r� 0
PL" Ct CHECK FEY, ,MR. Mi.f:LTIP11 IS;3tI.EsNCZ OF SAME K AN ?'TTalr,
CUSTOM 00140T.RI:lCTION 30M.00 31:
f+O CHIf"ATIO 'lSls.(10 SP
Qtat?Ld4GEWL-WORT `Pi3.n9 �1r
)TSTEMAM C06T OF C:C31:FINUM, 70N
120, ►.60
:PERP Ti 'EF. 9(3?1tYtirFA.RY
CONSTRUCTION IEEE 101.000-418.000 $011,00
PLAX CH.E. Y119 101-4100.439-418 $286.38
1ai1 CHA1NICAI,. VRE 101-000< 4 T 1 _mvo $111.00
.EL.EC7 I1JC, :L 1q:I' 101-0M420-00:0 $274.12
PI. UMBINO I' IER 101X000-4'19-00,0 Vol?$
STRONa MD710M ",F, . RESID 3.01-000-241-000 &W.CSS
ORA13190,PER 101 -MO -423,000 !r),0.60
TNFR+'s.STRUC'TURZ PEE 225 -000 -44'l -U2 $3.90.00
ART IV P1l13IW %fA&C - 901L Z10-000-445-000 $301.07
• � � �. � ..- -- rr DMS 1.33 .E NOW
i9iLITS
GF LAQUE.WrA
M�
RECEIPT
DA'f'E��'� v , o,
BY
NSPE O
-...
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
p'j,
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
eQ
F.A.U.
Framing
_
i
Compressor
Insulation
v
Vents
Fireplace P.L.
_ _ _
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail 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
Equipment Location
Underground Electric
Underground Pibg. 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
Pool Cover
Sewer Connection
_
�1dd—
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
COAW,
ELECTRICAL
APPROVALS
%
Temp. Power Pole
Underground Conduit
Aus
el*Rough
zt/
Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors t
Temp. Use of Power
3 3
Final
42
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:
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction
80-960 WEISKOPF
VM
Bldg. Permit No.: 0204-221
Land Use Zone: RL
Owner of Building: CAPSTONES GOLF WEST, LLC Address: 200 E. WASHINGTON AVE.
Building Official
City: ESCONDIDO, CA 92025
By: DANIEL P. CRAWFORD JR.
Date: 6/6/03
POST IN A CONSPICUOUS PLACE