0210-222 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chltpter 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
0.3/:411V
Date Irk `�"'Signature of Contractor --
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).
( ) 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 VATS. JFUND Policy No. 160313011-612
612
(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 thprovisions.
Date: t= °� 1 •> �- Applicant—
Warning:
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. r
i Any permit issued as a result of this application becomes null and void if ti
work is not commenced within 180 days from'6ateiof issuance of such
permit, or cessation of work for 180 days will subject permitato 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 propertyfor inspection purposes. f
Signature (Owner/Agent) Af o� • �^ Date—!
PERMIT #
BUILDING PERMIT
02-10-12.2
DATE
tiff
{ !, VALUATION U14,10 1.30 LOT �;�� +TRACT 29147-1
JOB SITE -'
APN
ADDRESS f 9i.FJo°1fI+7C1�Tc;�5
l�^dJ°IQl
OWNER
CONTRACTOR/ DERIGGNEFFN INFFR
Ct{ rOVMT, P.
Aff-JR\ZK DEVRLGCbP N# qRA ¢
;i 140 AVENMA RX(`MAS
5340 AAW IDA ES AS
CAPUMBAD CA 92008
CARIAMD CA, 92008,
USE OF PERMIT
..WCH Z17A i..Y'DW 1.I Na
SP 13, )W07' 4 1 >01 P., 18iR P011>! T DOES NOT 0CZvUT.& BLOCK NVPJAA
F`004 13PA 011 DW-VEM&YAPPROACH
CUO3` M CONSTRUCTION 2001.0111 SJt`
PORCHIP.ttsl'IO 358.1110 Sr
QhP.} QWCAR PORT 603.110 ON
94�.A D COM'OF 6Jd7'rRyC120B
XJ",10 7r0
iymrEr. qJp�liy
.
C ONSTRU"0110N 1'IE 101-000.418.000 Sj3 042,00
171AW t°HWIX 17f1:Z, 101-000439-31 $rf6 . 6i
MEC1.1 A:14TCAL 1!'RE 101-000.421 X000 st i t m
f�:l.IGCTRSiA.(. H 1;�� 1 t11 �fiUO-�.'�"��-Jlt1d? 1)1 `SSI.14
•
;�-��a�11��rJ��a ���� 1 �1>ac��41 �•e���0 S1Sf"�.n��
�'�
S'i'RM0 MOTION Y!1 E - i2. ME) 101-10W-241-000
,bRAl ING TME, J01-000-423.0610 SUN
ammopik IMP.ACT &'I:',m,
ART 1N Pl1RLIC." PLACOu' - kt< 2704)00-445 000 r?�
//$4,816.07
3C� S-`1"C71'Ai; i"t�1t i CI�'l'1Cii AlJJ� T'T.AW C;:I1}�CK
c $w1S+3n? FRIT -PAID 1 -SW
$0.00
OCT 3 i Aoz
aqt
WY OF LAQUINTA
"'
BY
DATE VNALgD
INSP C OR
t`7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
_
Forms & Footings
Ducts
Slab Grade ,6
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap Q
F.A.U.
Framing
Compressor
Insulation p4Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
17
Final
Final _ d
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
Waste Lines ���
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _
Pool Cover
Sewer Connection y
Encapsulation
,dye/
Gas Piping
Gas Test �� D
Appliances
Final
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)
COMMENTS:
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
CRapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
„� • Licend# Lic. Class Exp. Date
760335 B
Date Signature of Contractor
OWNER -BUILDER DECLARATION
03/31/2(
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.
( ) 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 STATE FUND Policy No. 1608301-012
(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.
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
BUILDING PERMIT PERMIT#
0210-222
DATE VALUATION 14,107.30 LOT 47 TRACT 29147.1
JOB SITE
APN
ADDRESS 37-665 SEMINOLE DRIVE
762-38,0-006
OWNER
CONTRACTOR / DESIGNER lEN INEER
CRV GOLF WEST, L.P.
ASHBROOK DEVELOPMENT COMPANY
5140 AVENIDA ENCINAS
5140 AVENIDA ENCINAS
CARLSBAD CA 92008
CARLSBAD CA 92008
(760)804.6868 CBL# 3376
USE OF PERMIT
SINGLE FAMILY DW n1_JNG
SFD - LOT 47 PLAN IBR PERMIT DOES NOT INCLUDE BLOCK WALLS,
POOL, SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION $501.00 SF
PORCHIPATIO 558.00 SF
GARAGE(CARPORT 605.00 SF
ESTIlVIATED COST OF CONSTRUCnON
214,107.30
PERMIT FEE gummARY
CONSTRUCTION FEE 101-000-418-000 $1,042.00
PLAN CHECK FEE 101-000-439-318 $855.50
MECHANICAL FEE 101.000.421-000 $111.00
ELECTRICAL FEE 101-000-420-000 $133.14
PLUMBING FEE 101-000-419-000 $197.75
STRONO MOTION FEE - RESID 101-000-241-000 $31.41
GRADING FEE 101.000-423-000 $15,00
DEVELOPER IMPACT FEE $7,405.00
ART IN PUBLIC PLACES - RESIL 270-000-445-000 $35.27
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,816.07
LESS PRE -PAID FEES
$0.00
TOTAL PERAM FEES DUE NOW
J\�
$4,816.07
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Cer
t fica
to of OccuDancv,
a
CityOlLa,Quian,tae-
Building
,
and SafetyD 6OFA'°
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: 57-665 SEMINOLE DRIVE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0210-222
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CRV, GOLF WEST, L.P. - Address: 5140 AVENIDA ENCINAS
City: CARLSBAD, CA 92008
By: DANIEL P. CRAWFORD JR.
c _
` Date: 5/28/03
Building Official =
POST IN A CONSPICUOUS PLACE