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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
Date {'-e2 % 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 Policy No.
��i�uI4..IIk;Y�9
(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, aid'agree that if I should become
subject to the workers' compensation"prov.sfons of Section,3.7,0,0 of the Labor
Code, I shall forthwith comply w't'h hos provision
Date: .4�� 9---4 1 Applican
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'inspoiciiolp uposesY'" '_>
Signature„(Owner/Agent)e'�^"'•
BUILDING PERMIT PERMIT#
DATE �/ j � VALUATION LOT 0105-067 TRACT
29147-2
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER/ ENGINEER
.P 107BRC)AiK :0EVE. +LtlPMf'..i1 T f.'-CX"Ag '.'
,P2ffl- ROOK Dr,,VK . YgdaWT r''OMP11MY
534'y{�p.f�'I�`.EA.�ryT�,�,.CJ�'*s 404
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C.!rt'NF LSBAID �...1A Yd.00 9
USE OF PERMIT
SILO -1+01' 91 PLATY S1t...raEyWIT DOLS NOT JNC1,UDYL BIA)CK 1, L1,
POOL OR DAItiLMAY"P32.OA£::H, 75% PIAN 09VIK "YEE APPIARD FOR
:AStl,,(XfPLV, ISSk9ANCEK OF SANTE PLAN °I YPY;.
!:tJ .1't 1.04 0M:STRUCT.10N 21,801,00 SY
POP_C%1PXV10 577,00 CF
'+EitPMi{toGMARfAORT (81# tiS 01iA
RM
P1 111M, Fla 90*&VAARY
VZF1 101-000-418.000 $1,1.10.00
Pt.Ail CIAZIC'K: VVII, 101-000-439-319 $226. ri
AidU11"ANICAL RUE 101x000-421-000 M so
tI.H.CT1t,ICAL KX 101-0,00-4M-000 $161.26
PLUMlNl1`0I ?1% 101-000.419-000 $10.50
VFRONO MOTION M,.12F-SID 101.000-241-000 S23.(A
ORADn4d MR, 101-000.423wf:1OI.1 "61A 119
x ZV9WPYJt IMPACT PER,
11Rk Ila PUBLIC P7AZW' - fQW25, 5-01CY $90.94
Mae, P11 M-1 Molar,
57
T W PRE -PAID M—D
OD
JUN 5 2001
' 'EVIIJUE
a? t° NOW
ar,3wamw
CITY OF LA QUINTA
FINANCE DEPT
r L'
RECEIPT
DATE/tom'
/// �Y. .
1
BY
DATE F NAL ��
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ _
%l llij�f /�
Ducts
Slab Grade
%��l ,ej`
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
O� 1 _
6I/
Exhaust Fans
F.A.U.
Framing
Insulation
_
��
`7�
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Dr�yvujaall -Int. Lath
Final
BLOCKWALL APPROVALS
Final
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
(p( _��`!G
Heater Final
Water Piping'
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
/Q�2�p1 (��
Pool Cover
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 a
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:
57-450 BLACK DIAMOND
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction:
Owner of Building: ASHBROOK DEV COMPANY
Building Official
VN
Bldg. Permit No.: 0105-067
Land Use Zone: RL
Address: 5140 AVENIDA ENCINAS
City: CARLSBAD, CA 92008
By: DANIEL P. CRAWFORD JR.
Date: 3/12/03
POST IN A CONSPICUOUS PLACE