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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 Y. Exp. Date
Date�� ! Signature of C or
w- -- OWNER -BUILDER DE' LARATION
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, aspprovided 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:
Cartier Policy No.
035-10-001M
(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 provisjoon`s.,of Section 37W-ot he Labor
Code, I shall forthwith comply with Pseor ,visions
Date: t, " ! Applican 'Fo
,,� 4.. --. • .
17
WNF ng: Failure to secure Wor 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 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 1.80 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 propert_.y4or`innsppetloon purposes.
Signature (Owner/Agen Date
BUILDING PERMIT PERMIT#
DATE �% / VALUATION TRACT
LOT 0�lh
p..,��3y ry)/y ry 916
V361377.60 29147-2.--
JOB SITE
JOB
APN
ADDRESS
�;'7• .°�2i4 �Eist#,C:� JV�1:t`t�F
7�.:�.•�� �tS�-i9:��
OWNER
CONTRACTOR DESIGNER IENGINEER
A4IRR00,YJEMLL�NT1 COMPANY
ptiA8yOICpMVvaOY(VWp CX:,W.aY
51 X50 ,A? -.,NWA ENCNA.Z'
5140 AWIMIDA ENM.1
CAMIMAU CA 92008
C;ARLS" AAE) (4,.k 92008
C.760)804"6868 aBLO 3376
USE OF PERMIT
SM) -C LOT119 PIAN 3S - PgPyk;�)Xpf�,M�tyi'aA"Y, 1401' INC,,,UDA 81,0 .RIA.,
�i353�}OKS
F001. M DRJ �' P.'WA if ;}T`PRC).iTdi. H.
CODST014 COMMUCTION 21901.09 OF
FORCHIP.ATIO 5'n.€0 Sr
oAn&o Jr,ARf0PT (SF) M50510
WMAITED C09 00 CONST i%00CION
2361107160
101 -000-4) 8-000 $1,119,00
:Fsd.A?11 CB•IK`.K FP 101 0- )'1 $906.90
MEC HA361(A1.. FEC USA
.a.,.
Kf. EC'TWCA'o1. FEF, $161.26
PUTIMBING FU tai �i9fat q•' a 001 ��, o t�
f3'�;Fi fJ iS9 t+- OTION PFX - R=31.0 101-000441.0DO
0RIADIMID FU 101 -000423-000 VIM 00
r1Ev riga o0PP�K s.MPAOT Fft t;=►ar . ur
A'3'+lT W P134LIC `1''S.rtiCHS - RWSI 103,at100-25;5, 000 00,04
TA,494.74
UJ B PRE-PATID 11:�?SS
$0.00
a FERMI YKES Mfg HO
w'�,�4✓'�#."��+1
JUN — 5 2001
RECEIPT,! BY DATE IN ED IN
FINANC ,�T �r
PE R,
' r, f •• ..r..wew.in.srnMnw
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I�p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_
�_Q-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
/6bf
Vents
Fireplace P.L.
__T1j
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
��Ri/oz—f
rywall -Int. Lath;lo
_
Final
Final
//'��
POOLS - SPAS
BLOCKWALL APPROVA S
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
Waste Lines
0-Ty0� (
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
�Q/�
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
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Certificate of Occupancy
I 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:
o
BUILDING ADDRESS:
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group
R-3
57-510 BLACK DIAMOND
Type of Construction: VN
Bldg. Permit No.: 0105-064
Land Use Zone: RL
Owner of Building: ASHBROOK DEVELOPMENT CO. Address: 5140 AVENIDA ENCINAS
Building Official
City: CARLSBAD, CA 92008
By: DANIEL P. CRAWFORD JR.
Date: * 1 /3/03
POST IN A CONSPICUOUS PLACE