9812-192 (SFD)I_ LICENSED CONTRACTOR DECLARATION
«- 1 hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
w - "32232 3r'NV501
Z r- Date ignature of Contractor f �/ ��
r' -F- � OWNER -BUILDER DECLARATION
J
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
Z_ ( ) 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). "
co () I am exempt under Section , B&P.C. for this reason
0
N Date Signature of Owner
ON
0)
d Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X ' W ILL. compensation, as provided for by Section 3700 of the Labor Code, for the
O J, Q performance of the work for which this permit is issued.
CIO I Q () ( ) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
a rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT Z Carrier Policy No.
co 0 UNTS C-01 I XF 1'1113 STAB i
0
J (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
3 subject to the workers' compensation provisions of Section -3700 of the Labor
Code, I shall forthwith comply with those provis .Z s.
Date: -,/-• Applicant �✓
77
Warning: Failure to secure Workers' Compensation coveragr unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspeectio .purpos)es. .
Signature (Owner/Agent) /,f r Date_ /
PERMIT #
BUILDING PERMIT !)M.7-192
DATE VALUATION �'� LOT 1 TRACT ryfi�ili-�
JOB SITE ,� r }
ADDRESS .S ;F. i.$ `rLIE iso i
A N 7469514Wi14
OWNER
CONTRACTOOR/DESIGNER ENGINEER
JY ROCO RX 77:y„ry Ii,0.MUS' S A, N `11 C.
Bi`ytHMID H01NIES SA 1.11EW 5Ni(..-.
128,65 Pc 3'i;t IT O)EIivUi. SU . ? i
a2 tci� � 3 i 3'i; .�}Ea.i1 MAIC Si 1M.”' 2W
,
DE1,1V1AR CA '32014-.8W
01s'.1, MAR CA W014-394
i�19,t4p,}-Si�i1{� C� i ,:r _k50
USE OF PERMIT
SINGIA PAMiC,V DWELLING
L0 s 1f, PL.A'K 1. Si° U - PERA 1T E it S WC f I N_, 'LLf.D i .J-3LiX".K W Ai. 0 0R
!X,%,X,%, K AW CHECK FES REDUCU) 7504 F OR MWA ME183'i3.t'<NC,E1
/1a • '. YlYVR1`iV ivaitaut,tTV
iittCFlrf�A\1113 319.00 Sb'
0AKA.CiN 0AJtPQRT 727,.f)0 Sly:
ES111,11MATE D WkNT OF
11Q 41
.41, -V Ice
flvitrklff EESUNINI.Ef►!lV
COiNS"1'R:UC11'loN FEY,101-000-418-M) 31.2t0.(K)
}3{;" r;i�F:("3� ! i+F 1(fi-!?diff-43gri1,R $q45 17
k11: IAMC ilia, #' 1:Z'# IM -000421-000 VIII. t11)
fi1,ECTWC;A1. F FIE lot -000-420-000 $180.54
(N! Ei441131-NOI w. 101400-419.000
S�f`ZONONI e't`t¢;114t'PFT."RF7'Affi 5101-000-2)414H)t)
GRAD,11'43 VY113 101.000-42-10100 X24).()0
1N1r A tt',fdU4�1'ii1C148.r 225-000-443-541; S5,754.13
AW]" 114 VILI8L.R, I'LAC'.ES M kESIO 701-0( -25, Oil) Safirr. )
81511-TOTALCONS" iGMON.AW-)PLA NCOt?C"1Z
$14,127k
LOSS FIRE"PAID FEES
$0.00
a1\�1;.;�s:.lvc�1W'
,,27.fi5
rRJ�CENA
DATE
BY
DA E I ALE &0INSPECTOR
J ` F
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
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
/
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
44
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) AV 100Y 7 7
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:
Use Classification:
�,...., I Occupancy Group:
SINGLE FAMILY DWELLING
R-3
55-727 BRAE BURN
Type of Construction: VN
Owner of Building: BROOKFIELD HOMES SAN DIEGO
Tom
Building Official
Bldg. Permit No.: 9812-192
Land Use Zone: RL
Address: 12865 POINTE DEL MAR. STE 200
City: DEL MAR, CA., 92014
By: DANIEL P. CRAWFORD JR.
Date: 12/18/2000
POST IN A CONSPICUOUS PLACE