9807-283 (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
695405 13 8131198
Date �'"- j -Signature of Contractort4
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:
CarrierPolicy No.
S1:A.� FUND" 212M-0 108:;5
(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
Codell shall forthwith comply wit those provisions
.
.lDe: - Z - FApplicant A l • it ' tiJ~t
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.
L,s3
IMPORTANT Application is hereby made Othe 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 witRP'all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon y
the�ab�ove-mentioned property for inspection purposes. xr
Signature (Owner/Agent) �p 1 Z _�,� R. Date4/- 2
E
- CONTRO
BUILDING PERMIT i PERMIT98011+
a
DATE VALUATION 1SJ.W).00 LOT 3 TRACT °� pL# � 5mg
O
JOB SITE
ADDRESS _51-440 AVFNI. DSA Gt�tt E GON
APN 773-0:91-6149
OWNER
CONTRACTOR/DESIGNER/ENGINEER
tiV11,{..1&Ah4 f:LrVfER DORAN
WILlSAm ra,MER LIX)RAN'
P.O. B0X 1_x''3
1224'W'.252ND 1'REEI'
LA (4UIWA C.A. 92.253
HARBOR Cf FY CA 90710
r
(110)534-3313 C:ALY. 33:30
USE OF PERMIT
POOL ANGOR SPA
POOL ONLY. ALtNRMS/BA1Wr-_ c,S SHALL BE IN iCl PIU-PLASIER
POOL AND/OR SPA 5,000.06 LS
F STIA111ATtIM r�`. M OF C0NSTRLIC17110N
PERAITT + 9 SUnri.ii4ARY
PLAN 01F.'CK FEE 101 -OW -4.39-318
CONSTP.11C.TION FEF! 101-000-418mo $77.00
N-tBC1•t VICAL, ME -- P001. 101 000-421.000
HLE.ClIUCAL. To -- POOL 101-000-420-000 i�aq.tty
PLUMBING FEE -a POOL 101-000-419-000
i
,tJ1 f1 .A I ('(jl t( -f("1 i()N ANT) Nl_.AN1 CHECK
'719 i'o(1
LESS PRE-PAJI 1 FEES
$0.00
PAISTO AL PERMIT FBiRS DUE tXONV
SZ14 SO
SEP 2 91998
f
R C IP NTA
/BY
DATE FINALED
INSPECTOR
J �
e5j.
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
OX 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
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Gas Test
Encapsulation—�i
_
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
t -
Final
Utility Notice (Perm)
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7177777777
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AND ALL APPLICABLE -CODES
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By —AslkhT��
REVISIONS lay
DATE
SCALE
DRAWN BY
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JOB NO
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DATE
SCALE
DRAWN BY
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JOB NO
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Pool size
Depth' 3 j -•�
Access ',s i
Fe cenFe R8R• Owner
Cont.
Elev. "Cr .���,
-L�
Crane footage
SPA size r 8 •�X
✓�L
t:.
Jets +.
.
Gas footage
Gas T stub yes
no
Elect. footage' g ,
Sub panels i yes.
no
Motor voitage
�no
Lites141c Pool s'f ' PA
°
,i
FI j
'J' -box's �-.-
Deck sq footage :.3 i "" 1:•
Type�Cant.1 2 Wil.
Std.'
$ '�_�•
Type finish
3 -•
EQUIP `
Filter Size ' lee
Type Cc a:r "
Pump H.P. A Q
Type
Heater Type
BTU
Air blower Amp. U
voltage
Booster pump -•-�- .
Diving board Size, ---r
Color
Slide Size "'
Color -7-
Ladder
Rail
Pool cleaner -
Type
Solar blanket Pool
(OA
Other V
Name
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Add. '.�/
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City 7w
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Tract t lei j7- !
Owner approval:
SUN SAVER FIBERGLASS POOLS, INC.
732 Williams Road
�— Palm Springs, Ca. 92262
.'Telephone (714) 323-4293
NOTICE: THIS IS NOT A BUILDING PERMIT �!
DISTRICT
APPLICATION TO CONSTRUCT yc
Permit No
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
284 199 9/74 CANARY—FILE, PINK—APPLICANT
Owner ""77 Architect 1 Contractor 1-2"11-) 5,�IUcP
Address Address Address.
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{N G, v l P. f ) 0
City- City_— City_L�
Phone 3W-1 7?� Phone Phone•• T (1 , -)Cf
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I (we) the undersigned, hereby certify and acknowledge .that I (we) have read the application and agree that if Curb and Gutter, and
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Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety
3
shall not make a Final Inspection, until said requirements havebeenmet. I am also aware that no work is to be done within the County R/W
O
without an encroachment permit.
t I (we) will not occupy said property and will not cause said property to be occupie until I ( e) have'
NOW, therefore,MApproval
complied with tawof-Riverside andthe State of California governing said property.
DATE • SIGNATURE OF OWNER AND/OR
by Signature from the Following Departments Listed Below
Must Be Obtained Prior to the Issuing of a Construction Permit.
(SPACE NO.
CC -r /��j�,^'(mss✓/lJj� USE OF STRUCTURE
V r
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JOB ADDRESS
/ SINGLE FAMILY [] DUPLEX E
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LEGAL DESCRIPTION OF PROPERTY
�, !J�C�C% 2l �c Z - APARTMENTS AGRIC. E
cam/ V
H
v ala- COMMERCIAL INDUSTRIAL ❑
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COMMUNITY .
ALTERATIONS n
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NO. OF SUBMITTED PLANS _—, USE OF PERMIT uW
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CASE N0. (= Com" C C t (41!11Z4
p .Z
NO. OFfP RKING SPACES REQUIRED NO. OF. BUILDINGS NOW EXISTING
Q
ZONE" SETBACKS: FRONT SIDEr -1 REAR
Co
GRADING PERMIT REQUIRED? YES ❑ NO ❑ LOT SIZE
SETBACK ORDINANCE # _— OF FEET REQUIRED ON STREET
DATE 4 SIGNATURE OF LAND USE OFFICIAL
t
DEDICATION REQUIRED: YES ❑ NO ❑ NO. OF FEET__
CURB AND GUTTER REQUIRED: YES ❑ NO ❑ -STREET
f
oc
4
CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑
j
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HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND: STREET
D
QC
IMPROVEMENT? YES C1NO ❑
°L
DATE SIGNATURE OF ROAD DEPT. OFFICIAL
=
SWIMMING POOLS PUBLIC
W
SEWAGE DISPOSAL _
FOOD ESTABLISHMENT
i
_
WATER POLLUTION REMARKS
�n FLOOD CONTROL f'
z AIR POLLUTION `£"f
W
_ DIV OFHWYJ°
c a — YOUR PROPERTY MAY BE SUBJECT -TO►
s .
c FLOOD. RIVERSIDE COUNTY ASSUMES
NO RESPONSIBILITY IN EVENT OF FLOOD..
284 199 9/74 CANARY—FILE, PINK—APPLICANT
DEPARTMENT OF BUILDING AND SAFETY APPLICATION CERTIFICATE
COUNTY OF RIVERSIDE PERMIT q
Effectiv* July 1, 1980, Chapter 1301, Section 19825 of the Health and Safety Code requires the execu-
tion of the following applicable declarations prior to the issuance of a building permit. Please
print or type and sign below.
0 LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code and my license is in full force and effect.
License C lass t/7 License No. 3 V 4V436
Date 91klK- — Contractor. u,- "-AoQf f-,
0 I/ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reasons:
Q 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. If I sell within one
year of completion, I understand I will have the burden of proving I did not build or
improve for the purpose of sale (Sec. 7031.5, B.&P.C.).
0 I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, B.&P.C.).
I am exempt under Section B.&P.C. for this reason:
Date Owner
Q WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a Certificate of Workers'
Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. Code).
Policy No. Insurance
Q _—Certified copy is hereby furnished.
(L-0 Certified copy is filed with the County of -.Riverside, Depart t of Building and Safety.
Date /y Applicant/_CI i �t
0 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
(This section need not be completed if 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.
I further understand that'if after making this Certificate of Exemption, I should become subject to
the Workers' Compensation provisions of the labor code, I must forthwith comply with such provisions
or this permit shall be deemed revoked.
Date Applicant
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the work for
which this permit is issued (Sec. 3097, Civ. Code).
Lender's Name
Lender's Address
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
I hereby certify that no excavation five (5) or more feet in depth into which a person is re-
quired to descend, will be made in connection with work authorized by this permit, and that no
building, structure, scaffolding, falsework, or demolition or dismantling thereof, will be
more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8, C.A.C.)
[� As owner -builder, I will not employ anyone to do work which would require a permit from the
Division of Industrial Safety, as noted above, unless such person has a permit to do such work
from that division.
[� Division of Industrial Safety Permit No.
Date Applicant
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY
I certify I have read this application and state that the information given is correct. I agree to
comply with all state laws a`nd`county ordinances relating to building construction, and authorize a
representative of the County of Riverside, Department of Building and Safety to enter upon the pro-
perty for which I have" applied for.this permit for the purpose of making inspections.
Satur�e oflAfpvplicant/Agent / / `-�' Da tel"
(rign'- leeIV-JP7rVN, -A l 4�J�.�ramf( �cr1�
Print Applicant/Agent Name
284-2000 7/80