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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
60 5
Date � '' Signature of Contractor; X `
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.
(V) 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:
Carver `Td°dTZ!!I�ND Policy No. 100890.1
(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' compensationpre'visiions of Section 3700 ofJhe Labor
Coded•shall forthwith comply with tMosefp ovlsi'o S
Date: o / � o T, Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation average 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 i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned pr rt for Inspection purposes.
6,�Ir*r rf Ott'
Signature (Owner/Agent) ✓� '¢• •- Date c.�t
BUILDING PERMIT PERMIT# '
mo? -i oi
DATE VALUATION LOT � TRACT
12M,377,W 81 29147-11
JOB SITE r 1 APN
ADDRESS7-tiiG}ti►�.�.i� �Ce iw5i
OWNER CONTRACTOR/DESIGNER/EN 1NEER
C`.kv C3O1,F W'1., r, LIP. IR8tTkI3oor,Y
5140 AWWf AI"sINUA'.+ S 5 14 0, AA'd1+1UDA:CENCINAS)
CAR3.,d ,?'Z Calk. 92009 01041 .1111:CAD CA 92WA
(766)804*69,68 (.'SIN 8376
USE OF PERMIT
SIFD - LOT 87 K.AN 3•A.R . P FAMI T OUYS RI03' rNCL;UL' P_ BLOC IC
CUSTOM CONSTRUCTION U011150 SIF
(Vi,RA0FJCAVP0RU 13406 SP
X, UrMATW C037
.PERVirr M-2 L�1'U 'JAl'4 rty
CC'?NSTRUCTIC R FEE
101-000-418-0010
51,119,013
PLK14 C114E :9 FEE
101.000.439M4116
$906.S(t
MECHANICAL FIM
101-000-421-000
$85.50
El;W. Til.It;<'�2,. PEE
101.000-420-000
$161.26
PIa1N?P.IWO PRE,
101-000-1119-000
UK,"
STRCNO MOTION FRE .,1x%;11
101-000-241-000
$T31 64
CIRIADINO r -U?
101 ,,MD -423.000
$20.08
DZVEM)PER IMPACT P92
4auo
ART 414PUBLIC K ACES •- REEK 2703 000-445-000
550,94
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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
ZExhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
_
Fireplace P.L.
_—Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Dryuva11- Int. Lath
lYL
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
Waste Lines
r�j ,�
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral/�
Pool Cover
Sewer Connection
�la�Z
Encapsulation
Gas Piping
Gas Test
_ _
3/33
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
3 D
Final
Utility Notice (Perm)
,- Certificate of Occupancy
196T
0F'T9ti Building & Safety Department
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: 57-550 BLACK DIAMOND
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0207-101
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CRV GOLF WEST, L.P. Address: 5140 AVENIDA ENCIANS
City, ST, ZIP: CARLSBAD, CA 92008
.!dam By: Daniel P. Crawford Jr.
Date: 6/25/03
Building Official
POST IN A CONSPICUOUS PLACE