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17,
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
%212,K B
vDated - % r' QSignature of Contractor -/f y
•U v�
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).
O 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.
SecI have and will maintain workers' compensation insurance, as required by
tion 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.
iN5 Co OF THP~ SI TAI RA4WC ,-05n4>
(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.
Date: Applicant
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.
t 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.
I Signature (Owner/Agent) :Date /- 7 Q - i
BUILDING PERMIT PERMIT#
9�lli.i-07J.,
DATE VALUATION LOT �- -TRACT
$262,641.9x►
q imillow
JOB SITESl�i
ADDRESS 1,41r 1'760-530.006','.,
p r<iR t
-....Ue.
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
k;k0(.3Ki° ELD HOMES S.;N DIEGO 1'ivIC.
BROOK IFLD fiOMEM SAN DIEGO MIC.
12865 POIN' "F,. Dr 1. 'MMA (1, SUM. E 200
12$65 POINYTT bE , h1,A 12a SUM 2t00
DEL MAR CA 4,2014-3859
DEL MAR Cts. 92014-38!.
(019)4$1-8500 CiiL# 3350
USE OF PERMIT
SINGLE kAM.111Y'1)%TU .INQF
LCUT 17, PLAN 3, -SiD- MTi91T D009 NOT LiNCLUD};BLOCK WAI I. CM,
P00A.. PLAN CHECK FEE.REDUCEi3 750:16 FOR NfUMPLE3 ISSUAN(MOF
SA &- PLAN TYPE.
CUSTOM CON317-R 3MION 3.10.003F
PORCH9ATIO 519 .0 ISF
GARA.GECARI'033T 727,00 S'F
ESTINIATIA) C OSI' OIC" CGINSIT>;tUCIICIN
262,641.90
PERMIT FEE SUMMARY
CONSTR[3CCION FEE 101-0(W-4.19-000
PL.NN CHECK FE 101-000-439-318 3215.:97
MEMAWIC AL ME , 10 i.-0(* 42:1 _000 $92.00
0XICTRICAs. FEE 101-000-420-000 $13034
Pi'll,T IBING FEE 101.-000-X119.000 %132.75
S`CRONO ICITION ME - RF,41D 101.000-241-000 526.26
GRADING FER, 101-M-4234100 $20.30
WF12ASTRUCTC)RE FEE 24"23-000-443;342 $5.754.13
A11T'fN PLIAL(C PLACES . RLS11, `i01-(id}0-253.000 $406.60
S(.'IY.Y,�:��d� CONS T ittlC l'IOl<i ?ktV C:1'L1�1�i L.[,ILCf
L£ SS PR43--?!D ILLS
I0
APR 21 1�9 -DOTAL rFT�NIUT FE, ES ��r� Nr�ry
S8,127.65
3
tw 1
RECEIPT
DATE
By / w--�'
DA INALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs iA 4 A
Underground Ducts
Forms & Footings 11
Ducts
Slab Grade V
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing le
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 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 3
Encapsulation
Gas Piping
Gas Test S v
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
Final444*
Utility Notice (Perm) 71 V(1
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:
55-871 BRAE BURN
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction: VN
Bldg. Permit No.: 9903-073
Land Use Zone: RL
Owner of Building: BROOKFIELD HOMES SAN DIEGO Address: 12865 POINTE DEL MAR, STE 200
Building Official
City: DEL MAR, CA., 92014
By: DANIEL P. CRAWFORD JR.
Date: 4/25/2000
POST IN A CONSPICUOUS PLACE