0105-075 (SFD)LICENSED CONTRACTOR DECLARATION
I he affirmyunder 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/.- -j ~ _„ Signature of Contractor'^;~' ✓sem ✓
- - - 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).
( ) .1, 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.
(�) 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.
(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-p"rwislons'of Sect�_31.Q0 of the Labor
Code, I shall forthwith comply witli'th6. prov",is s.
DateL � � Applicar(t �1�� � ^^
'"'"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
application.
1. Each person upon whose behalf this application is made & each per t .,
whose request and for whose benefit work is performed under or pursu
any permit issued as a result of this applicaton agrees to, & shall, inde ify
& hold harmless the City of La Quinta, its officers, agents and emplo s.
2. Any permit issued as a result of this application becomes null and id if
work is not commenced within 180 days from date of issuance of uch
permit, or cessation of work for 180 days will subject permit to cancel) tion.
I certify that I have read this application and state that the above informati n 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 propertyfor ins action purpq5es:---^-�,,
Signature (Owne.r/Agent) °' Dateig: ���
BUILDING PERMIT PERM T#
DATE / VALUATION LOT �;� TRACT
=I.RS7.40 44 29147-2,
JOB SITE.
APN
ADDRESS
7-1AINi��i
5OL19•)WO
?Q�1-R dA tib.
OWNER
CONTRACTOR /DESIGNER / EN (NEER
JW,t,`I, ROOK C'OWANY
ASMROOK OK M-"�i� OP,PiiF3,V 00W.
5140A',fl.RMARH CMA0
5140AV12 Ai MAU
CARLSBAD Cr':A. 92008
CARMAD CIS. 92009
USE OF PERMIT
3FD - LCAT 44 PIAN M, - PERWI T DOM NOT INCLUDE SLOCKW,ALL,
i`'OOL OR DRlVWAY APPROA.0 H. 7aw`yo.PLANK C:14 RCK .F9,9, 4PP11Q:D FOR
:AFlI3L'b' PIP 15KJ"@UA'1'ICF: OF EMP, PLAN TYPE.
CUBTOM CONSTRUCT1014 %61.3.VP -Sr
PO3 CHIP.AT1O .524.0 SF
OARAOMA.RPORT (I 2AAft.40
MIMAnM CONT OF CORUIRM 110.N
221,157.40
.1'1IRMT11 111PIR SUNBU1RY
CONSTRUCTION FEE 101-000-418.000 ".54.30
PLAN C'II'IFA* FEE 101.400-439-1 18 $193.-A
MP.MWICALFEF. 101.000.421.--000 $83.80.
94..9XTRICAL XV, 101-0M420-000 $121.'71
PU:D£t+ BIND 101. -00-419.000 $162.30
S"Fk1,S3MMOTI.0H ME-'IESID 102-000-241-000 V9.00
C►RNADINO V2 101=i3t1�r', 2 htJt7G �36..tlia
D1P4t~L+,WPER IMPACT FEE 3' _.aw sI,PR'1.1)I►
U'U
C099MUM, ON AND PLAN CEMICK,
$3,463.94
JUN - 5 2001 -PAAD F.U.2
so, Do
$3,4663,94
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE BY
DATE FINALED
INSPECTOR
*, • M. ZI=Koj•
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
^�kBUILDING
APPROVALS
MECHANICAL APPROVALS
Set, acct -
Underground Ducts
Forms & Footings3
Slab Grade
Steel
Roof Deck
_
,� L_
ZZ ..�,�/
9 _ Q
/
Ducts
ReturnAir
Combustion Air
Exhaust Fans
0. K. to Wrap
3� (aN
F.A.U.
Framing
Insulation
Z/� (,'
a �Ji
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwail - Int. jth
_
Final 3��1 d �oZ �«,
BLOCKWALL APPROVALS
Final
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
_
Waste Lines (p�fi/� �/��
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
��1j/
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
(�� �'lY✓/GS��
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 2
Utility Notice (Perm) J/�
4 .
Certificate of Occupancy
City of La Quin'ta
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:. 57-615 SEMINOLE DRIVE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0105-075
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: ASHBROOK DEVELOPMENT CO
Building Official
Address: 5140 AVENIDA ENCINAS
City: CARLSBAD, CA., 92008
By; BILL GORDON
Date: 3/20/02
POST IN A CONSPICUOUS PLACE