0311-240 (RPL)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
MCI
794354 B U
Date' ° �'� Signature of Contractors rl�l�r"-�* �•
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 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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those prov sion5.� ,✓ �r
Date: �2'17 Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct!1 agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
above-mentioned prop��ertt�yy'for inspection purposes. f01
Signature (Owner/Agent)`,',/' ' � t. .�. Dater 4
r.
B ILPING PERMIT-; " PERMIT#
DATE VALUATION LOT D31 ' "AO TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MILO A DORAN CONSTR MON
Iv L0 .A. DORM CON M'F.tiJC IOXT
72960 MR -0 WARD TCr DR 41
72960 FM WPRMC DR 41
PKLMi3ESEwT CA 92260
FIA11IIDWERT GA 922060
Q60)4.13.2693 CBLO
USE OF PERMIT
FOOLA fJ3/(3R AP.A.
Pt;JWSPA, 10 .LF. 4' EQUIPIdLLt'd$'I`WIi1. I, ORCO 6YN'P&M
A.t;,€;lM(113AMER, :��LALL 8F, r14 PI.,hOT AT .FR9,PLAUTFI,. i348P&'_'TION.
4 FT. MALL 10.00 LF
POOL ANDIOR ISPA 9,840.00 1.,S
ES—MIMED C01.7r OF CONS'MUM014
!01000100
PLAN CTIEiK FEE 1.O1-000.439-318 Mos
CL., NS1'6Z.Ltd:`t'ION M 101.000-418-000 $1I9.Q0
1tAE+ H"1Ct,L rTE -- POOL 101.000.421.000 $24.00
F",,CTRICAL FEE- — P xOL 101.000-4.20-4SO0 V31061
T'I.tIMANO FEF -- POOL 101.000.419.000 $2 7100
SM -TOCK C0WS: UC.'1`10W AND Pi.xttsl••T 010
S289.0:5
]L'S FPX4,-PAX) KE19
$0100
'%'OTt3L'IVOMIr
FFX4 S DUP, NOW
S2.89.05
DEC 0 9 1003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE/— t •f -^
BY
DATE FINALED
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
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
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
X -
Set Backs
Electric Bond
42.
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
.D
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
u
vas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
1001-01,
.f)-
Lj\
r -n wus x h oun-toum It nidi 1 L,n'L IS
Z47!JOB ADDRESS' �' o? i,5't� VJ-44"' PERMIT NUMBER 0311•-a?�U OWNER )2ZtZ_o_ JbA1APV.-_ BUILDER o 04 AAkak tcats.L,
N. This form shall be posted on the job with the Buildinv�inapaation Card at all times In, a eonsnlarous Q]e. Only persons appearing on this list or their employees are authorized to work
i on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
M• ` of buildingpermit.- For each applicable trade, all information requested below must be'completed by applicant. "On File" Is not an acceptable response.
Trade I CNsiftatios
Convector
8iate Contractor's Cleanse
1Norkere
ei;satteii insurance: •'
p —O C Business Ucense'
Company Nom...
ClassificetiCn
(e.g. A, B. C -el
License Number
Ixxxxxx)
Exp Date
ixxtxxfxxl
Cerner Nems y
(e.g. grate Fund, CaICanWI
Pollry Number
IFCmnet Vales)
Exp- Date Lleenea Number
xx/xxlxxl Ixxxx)
Exp. Date
(xx/x xx)
EARTHWORK (0-12)
r!9
c x>reiC�ua
. . V -,U rre- GT
° P>
G
FRAMING (C-51
`
STI ICT. STEEL (C-511
MASONRY (C-29)
<
_
unAetNG (C -3e)
LATH. PLASTER (C•361
% ?
rc G' 2 j
/ J•/ 7 �i''i > S
�'•I i
DRYWALL (C41
HVAC (C-201
.� C. J•
'
LECTRICAL (C-101
ROOFING IC -381
'
SHEET METAL (C-431
FLOORING (C•15).
GLAZING I6-171
-
INSULATION.(C•21
SEWAGE W&. IC -421
c
PAtNTING IC -391
CERAMIC TILE IC -W
CABINETS (0.51
t
FENCING (C•13)
LANDSCAPING IC -27)
�/
v
POOL (C-53)
p—
:r