9903-072 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- 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 = License # Lic. Class Exp. Date
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C:) Z r- . Vbatel V Signature of Contractor
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CID
:j OWNER -BUILDER DECLARATION
W 'Wca
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 0 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).
Cl) () I am exempt under Section , B&P.C. for this reason
LID
N Date Signature of Owner
O0
U Q 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.
TINS CO OF THE ST:kT 'RMWC 347-05.26
(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.'" -1
t ate: F7 r -or Applicant �1
r i —
Warning: Failure to secure Workers' Compensation coverage ' 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 jf
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 at
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.
gnature (Owner/Agent) 1/(�r �' .'r• i Dates Z��
✓ �� –
BUILDING PERMIT PERMIT#
DATE VALUATION LOT "341,7,2 TRACT
4 . 2-o A y $267,64:1 >90 lib' j ��i"�*� 28341:2
JOB SITE
APN
ADDRESS ;,5!%5_ Pyyi�r
769-530-0046
6
OWNER
CONTRACTOR / DESIGNER / ENGINEER
BkOOKFIELD HOMES SAt'•i DIEGO INC,
BROOKFIELD 'HOlC ES SAN DIEGO INC.
11865 PO[NTE D,61, NIAR, SUTM 1.00
12865 POINTE DEL h4AR SUII`E 200
DEL MAR CA 92014-38 8
59 DEL NLAR. CA 92014-A'
`
(619)481.8500 CELL# 5350
USE OF PERMIT
Atdf 17 "- -,Nuf y nurvi 1 i
LOT K PLAN 3, -SFD- PMMfT DOES NOT INCLUDE BLOCK WALL OR
P(X)I..PLM C1TEO. FEE REDUCED 75° o FOR NOXT[PLE :t3SUANCF O
SAA"fE PLAN'1'1'PE.
C i1STOtM CONSTRUCTION 3,1rm.01) SF
P0iiC%1/PKf10 519.00 Sr.
CARf100C. ARPORT 727.00 SF
€�b'1'IEVI.�'.�`ED CGS OF C�.iTaNST.�t(li';`1'lf�l�i
262,641.90
PERMIT PEP SUMMARY
Cc sNSTRUL-110N FEE 101-000-418-000
PLAY CHECK FEE 101-000.439-318 � $245.37
MECHANfCM. FIM— 1101-000-423940 S9'x,00
1:LECTR1CAL I?`1r7:x 101.0001,420.000 $1180.M
PT.UM B1NG FEE 1()14W-419-000 $1.92,75
STRONG MOTION FEE - RES1O I01. -00(f-241-000 $26.26
ORADI NG FLM 10t-000-423-000 520.00
11`TfiA,$TRUCTLfRE. FE'6 225-000-443-342 $5,754.13
w1 :rNI?t373[;IC 111,AC I39 - RES.IC 7p01-000-255-000-1flb.ti0
APR 25L' ff.Ab C�?NK?'E.V OKND PLAN CHECK
$81'127;65
LESS PRE -1',A A) k%EMS
$0.00
JbTAL PERAfITi'EES DUE NOW
58=127.tS�
RECEIPT
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del iVl
INSPECTOR
-M
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
y
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
S/
Final
Final A4POOLS - 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 S Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection $I J, 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
City'lo a-Quinta
Building and fetyDepartme,
nt
. �
This Certificate issued pursuant to the r&quirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issu.ance, this structure was in compliance with the various ordinances
�r
of the City regulating building constriction or use. For the following:
BUILDING
Use Classification:
Occupancy Group:
Owner of Building:
ADDRESS: 55-855 BRAE BURN
SINGLE FAMILY DWELLING Bldg. Permit No.: 9903-072
R-3 Type; of Construction: VN Land- U.se Zone: RL
t
BROOKFIELD HOMES SAN DIEGO Address: 12865, POINTE DEL MAR, STE
-ro�t-L
Building Official
City: DEL MAR, CA., 92014
By: DANIEL P. CRAWFORD JR.
/ Date: 7/21/2000
POST IN A CONSPICUOUS PLACE
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