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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 Y f Signature of Contractor y /fes-�
! V
OWNER -BUILDER DECLARATION 0
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.
(,c,) 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.
J NIN co OF 11111ESTAI
11MI ti'C' 347-G32.f
(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. r"�- `
Date: y Applicant �' ✓�� /
1-7
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.
Signature (Owner/Agent) ✓�/�'/ _� : Date -7')/ 0 -1 !.1
PERMIT t/
BUILDING PERMIT
9912-18410
DATE VALUATION SZ62"s.9 .1 (4' LOT 41 TRACT 28341-2
"?
.71JOB
SITE
ADDRESS 5457-E►U.7 BRAC HORNN
APN 70-,510-614
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Hk'.. 015 11»ID HOMES SAN 011"'G ? Mc.
BR,01 KIFIE .:.f2 F-10 €ES S,'`IN D1"EGC) INC.
i i51� riiJ°d't ;I i ,MAR. dill C� : 00
.12.865 POINTE 1'3ELA4:AR, SUME2100
DEL iUIAR, CA 92.014-3859
G)EL tiXAR. CA. 92014-38.'
i9)4R).:d..W. C BL.A 5.350
USE OF PERMIT
STASt`iLE PAWL LUNG
LOT 4, PLAN x. SFU - M"IT DOES NOT INCLUDE BLOCK WALLS OR
POOL. PLAN Q%C'I<.:E fX' ltL-T)UC`r-D 7S:e FOR NILILTIPLL ISSUANCE e, F
Slw4 "f L Adti TYPE.
r10All CION 11riju rr4f.14 3.100.00 ST
1'Olkell/111"1 > 519.0 Sb
tfA�Ai3lil�:Alt;k'C�12:7' ;"�?r.pa Sf}
.d V 1 iVUb:r,3tA' 1+tPY& a..ri` (MINI Y'\., U Ye .IDN'
2,62,44, 11901
CONS1Rt.€CTI(C)N1"E'£; 101-000-418-000 $1,210,00
) TAN r'[.s : ; " ;r € (14 -W-439-31$ $245.17
vG'PITANICAL n!,E, 101-000-429.-00(} 592.00
1 F Vis::' RICAL i'l.E i.0€-000-420-000 sigo,.`4
) W -W -V -000
01C..' DING SEE, 101-000-19'"I'll-ow
iN[1ecAi f AVIV €`0.Rli F11c, 225-00443-342 $5,15,t 13
AR'f IN PUBLIC PLACES - ESM 701 -OW -2-55-000 S4f1(i,titd
5 3R» €' !` L. C. 0N5" LX,' "i0?�€ AND PLAN CHriC K,
,127.65
Wli.Ad,,P6r<w'ba.idUT 1FF.,5 01UF,,1N NV
$8,127.0
`RECEIPYf
DATE
BY t! `)
DATE IN/ALE
INSPECTOR
t
INSPECTION RECORD
OPERATION 7F77;ATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
DWall - Int. Lath
AOL
Final
Final
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral X
Pool Cover
Sewer Connection 10
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final 06 gt 612
Utility Notice (Perm)
COMMENTS:
Certificate of Occupancy
City of La Quints
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: 55-663 BRAE BURN
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9812-188
Occupancy Group: R-3 Type of Construction: VN
Land Use Zone: RL
Owner of Building: BROOKFIELD HOMES SAN DIEGO Address: 12865 POINTE DEL MAR, SUITE200
City: DEL MAR, CA., 92014
Building Official
By: DANIEL P. CRAWFORD JR.
Date: 11-16-99
POST IN A CONSPICUOUS PLACE