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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 r,.., Exp. Date
s
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
O I am exempt wider 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.
(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' compensationprovis,- sof Section 3700,04he Labor
Code, I shall forthwith comply w7th�tY�o'se 6visions. ,
Date: Applican4 - - -
Warning: Failure to secure Wo K rs' 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 hist
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
construc'?on, and hereby authorize representatives of this City to enter upon
the above-mentioned propertyfio� inspe ioh;-purposes.
r err �, '" a
Signature (Owner/Agent) r
Date-.-
BUILDING PERMIT PERMIT#
DATE f VALUATION LOT 01,05 d11S6 TRACT
$221,157,40 91 2.9143 -2i
JOgS(TE--�-... �_,..
APN
ADDRESS 57-4070MACK IMh6)
761-.1-110-1131115 y"1-11 -6 15
OWNER
CONTRACTOR/DESIGNER/EN INEER
140 M: k IDA;1"�,�.1'MAS
;5140,t1M".�...I�'!rl7ARNC~ AS
d;.MRLBBAD CA. 92009
CARL&RAD CA 9MA
(,?60)$0"106f3" MIA 3376
USE OF PERMIT
SAM..) . WT 91PLAN N 20 - PERhI T %il'.D1.:i'hlW NGrkUDE, tILZCKWALL,
CU TOM E".rb.+!'137'RUCTION 2,611,00,sp
pORi"N9P:rpp T'IO MOO SP
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IrSAMWATFUN (MST 01V COMMUCTIO-K
221,1$7.40
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'M�4.+9y'6eFA�1 UM1011 .VVEY, 101=000-'rP.74Yy4)f 0 `934,50
PLAN CKWK, FEE 01-000-439-318
MRIC+`HAN$FLtAL VJ99 101 -fit -W-421 tl000 �t35.9D
ELECTRICAL L F99 101 -000 -4'20 -WO
PLUIMB1140 IM, 101-000-419-000 S16150
1t° wk ft31'T.C�SdVf�r�81t' ILI 101 -000 -241 -WO $.19.00
GRADING RK '101-000-423-000 $20.00
X)Y—V2101:+1-0.1MPAZT FKE 133Y9U1f+U
MIM. �'0T.A.; 'TC;710its AND PLAN Ux1E;C.YC;.
$4,04;5.11
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LESS : H-ri.-PAU)1° 111Q15
$0,00
litl
JUN - 5. 2001
CITY OF LA OUINTA
ECEIPT FINA
%-OPT
Y
DATE FINALED
02—
I CTOR
u-(,�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Main Drain
Bond Beam
Approval to Cover
Set Backs
Forms &Footings
�b111
G�
Underground Ducts
Ducts
Slab Grade
��/lD
Cir�Q/��
Return Air
Steel
Final
Combustion Air
Roof Deck
�� b
Gas Test
Exhaust Fans
O.K. to Wrap
��
_
F.A.U.
naming
Insulation
Shower Pans
_
C mpresr r
Fireplace P.L.
Pool Cover
Encapsulation
/
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall_
Exterior Lath
//��rj
Drvwall - Int. Lath A
/�, ji n/ A
/ x�
Final
— �(c3 a2 �ccC
BLOCKWALL APPROVALS
ruiai
dPOOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
G. F. 1.
Main Drain
Bond Beam
Approval to Cover
Final
Equipment Location
Utility Notice (Perm)
Underground Electric
Underground Plbg. Test
Final
Gas Piping
Waste Lines
PLUMBING APPROVALS
/�j�( Ag
Gas Test
Electric Final
Heater Final
Water Piping
-
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection!�/?y�� 6i(�
Pool Cover
Encapsulation
Gas Pioina
`1 Final
ELECTRICAL APPROVALS
)le
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F. 1.
pDetectors
Tem.
Tem .Use of Power
Final
Utility Notice (Perm)
COMMENTS:
4d
'614
I
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: 57-470 BLACK DIAMOND
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0105-066
Occupancy Group: R-3 Type of Construction:
Owner of Building: ASHBROOK DEVELOPMENT
COMPANY
Building Official
VN Land Use Zone: RL
Address: 5140 AVENIDA ENCINAS
City: CARLSBAD, CA., 92008
By: BILL GORDON
Date: 5/13/02