0108-311 (BLDG)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
4
D5�� 3 IZC
1r
Date ''" �'r'? Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty cf perjury that I aria 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.
(r) 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,
.11-s�Aall 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 shallforthwith comply with thoseprovisions.
'. i. , . ': , If ! Applicant j'e
Date: p,
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 Safely
for a permit subject to the conditions and restrictions set forth on his, -
application. s
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�(OwherjA'Ont) �i Date
BUILDING PERMIT''PERMIT4k IF
DATE VALUATION LOT TRACT s
ilE�9"2 I2Cb "5, : ad�J 122 C1
JOB SITE -
APN
ADDRESS
W-723 SAGUARO DRIVE
-
671400-022
OWNER
CONTRACTOR / DESIGNER / EN (NEER
'WTUIAM DOMMU
S:.3wOA,CY HC?Wt1l
3402 T'WO .3~:ttiLL
y
47 -7 5 0 ADMO MMMU 1426
UA,NTA. ANA CA 59-2705
LA QUNA CA 9225'.*3
(760)564-7820 mia o2or"?
USE OF PERMIT
gs3 NY—U. A e Will ANG
225 fL' COMM.) !' RY TAT1QIW(.V5` Sk"02W WA.LL-CIT Y S T.ANI,?.AM)
4-.-
0 F'° WALL LF
COST OF CONST t�,?4'''.k11Q' PT
y� p,,r� q �6rpw q;,e� p 1 yry g� q yMWAIRD
.R�AS4wlY:t:Yd,l�.9. RIK'L "�'{JS`Vt. L�.1h R X
+.
COMTRUCTAON FEE 101 -000-416-000 $91A
� F3'c l' i-'x°C3T'A a 14 RUC' 100 AND PLAN- CfMC
L^' IXA93 FRS -PAM PIWI
D
AUG 29 2001,:���°�.,,:��
CITY OF LA QUINTA
.
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings ,
Ducts
Slab Grade i i
Return Air
Steel I
Combustion Air
Roof Deck I
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing }
Compressor
Insulation
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall ]
Exterior Lath
Drywall - Int. Lath I
J
Final
Final I
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
_
Set Backs ! Q— S —O S T
Electric Bond
Footings }
Bond Beam } .12— _�/D �
1 ,
Main Drain
Approval to Cover
Equipment Location
1 I
Underground Electric
1 1
Underground Plbg. Test
Final !
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines !
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral }
Pool Cover
Sewer Connection 1
Encapsulation
Gas Piping 1
Gas Test I
Appliances {
}
Final
I
I
1
Final }
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole 1
Underground Conduit
Rough Wiring I
Low Voltage Wiring }
Fixtures i
Main Service i
Sub Panels f
Exterior Receptacles
G.F.I. i
Smoke Detectors
Temp. Use of Power
t
I
Final i
Utility Notice (Perm)1
COMMENTS:
i