RPL (9806-101)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
,�qhapter 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
(53 _V31199
�Signature of Contra'—cl 4 44
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is riot 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
bate Signature of Owner.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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.
f 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.
CtAIG )0,& NS, I
(This section need1not be completed if the permit valuation is for $100.00 or less).
J,'):qertif'y. 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 o ' f California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
d I shall forthwith comply with those provisions.
a t
e .I — 144 _� Applicant
Warning: Failure to secure Workers' Compensation co rage is unlawful and
shall hall 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 th6 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 upofi
the above-mentioned property for inspection purposes.
ti
g'ature (Owner/Ag Date te-7ze A6.
BUILDING'- PERMIT PERMIT# CONTROL#
DATE VALUATION LOT TRACT
Jf 7926
JOB SITE
ADDRESS 54 455 AV14,2411M MENDOZA APN
OWNER CONTRACTOR / DESIGNER ENGINEER
FR
2318-S. VINEYAXD.AVENIJE
LA QU!N'TA CA. 92253 OWAR,10 CA. 91.76.1
w(
(909)q,VW74 C91.4 5240
1 USE OF PERMIT
POUL
PoOL clucv" Wo 'WI'ATHR /,ALA"1S/tARR.fiNS SA.41.1',.1313 -6Pr_-'RXX-K)MmL
'PRK>R. TO PUP.L&SKVW INSPEC"110P4
111,100L ;OVOIZ "IPA
ESTIAIA FED COST
PJAIRMI.Tr(CV, SWAWMARY -
11;,, AN 0417,CK, Ff.-F 516.05
CONSTRVMO,!I�!70 $1 II7.po
W3C_'r,1U%C1% V.IiC — POOL toll _000: 110
_1114m, $45.00
i.,11LUNW0,W) Pull —'00011 $17.06
4
,tD UC711301?-AN ['t .AN CHECK
i.xs*s Piu-,P.AtD.-r-vxs
JON 1.2`1998•.`
RECEIPT I DATE I BY DATE FINALED I INSPECTOR
i
10.001.1019
$265 05
$0.00
$265.4.05
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Un ound Plbg. Tes
Final
in
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
Gas Piping
Gas Test
Appliances
Finals —
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
l
c
Final
Utility Notice (Perm) i
COMMENTS:
4E&Vb-rI NA
5%-4e>
P/ t_.
Pool
SW" 1954
(909) 947-6474
(800) 479-5560
Fax (909) 947-4393
I 140P%mOF &~ 2316 S. vinevard Ave.. Ste. A
Ur- No. GISM-C,53 Ontario. Cw9dommi 91761
-rgomArs C7 V I OG
tv\? b-iq —F>
"T T' C.,
B
--V
i: DEPARTMENT
ACCEPTED FOR CONS"i".RUCTION
SUBJEC1 INSTALLATION AS' PER e-
T
ADAPPLICA u
A' KE CODES
13Y
w ��
op
ql Fu, 0
GVNEFAF`pluA'n0NS
EXCAVATION\A_.��
ACOM � AW
Sao cat ShUW@ Dig
RWTW49 cxn* —
Remove Smunalsl
Rwrkw4e Fence —
Room* Force
Parram Carcram S..
STEEL
Emarm" Sad St" P=lr"—
PLUMBING
Fww him � v2.L
Rewm Urns
eacxwasn Lww _0 Trw
Gas Une_F%; _
ELECTRICAL
Rut By Fig- 15,
GUNITE
L&Ife Sea
Swint ou
Ext. ad Sup
pw — In X Ft.
Rbb Im x FL
COPING
Typo ST
TILE
Type
So& Dam
A=u Ti*
VECXINQ I
Tyne C-bmcpF- -rr—
Exoartmn .corm
Fomrigs
M&TIC
Dramm YES
EQUIPMENT
Ame TYPO CART Smj=
pumo k !'I. ho
is-- (I
smartsax
'Ves
Amamagic
Ves
Smamugm
Yes
SW W Lignt
tR@D
SenarfVaC
yes
E-Wgy vac
yes
Heater —m. Na:
Board
Side
Sheet 06308M sal
PLASTER
C--Aor \rM'VE
SPA
SLW
PIUMCirQ PAJn
Darn Wag Larqtli=
Numow Of Jm
Blower H.P. Yea
pmTKm—LAWallp —
Saa Side SwnC:h Yes
srmard4m yes
im wan Ugm Yes
Bu
MAW
...........
. ... ......
• Appra4e 000mW7t kX=On.
• Uncergmnd em aecWng snown is for Custra-um Pu= -342 OM
w4armand Vint TWf ara= scpja . M feet ot cac
SigrAwl
Prepared F-specia-Ily For:
Sweet Ave ----
Cw L -h QLAIM71--A- Zio cl-- pg�>
ho.,* Ptc,,* -7 -11- 3 (p6r-1 %vo,st Ptx"
Oasigrw
Lot Blocx
A-fN-NO. -1 4-111-01S
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0
0
a -
BLUE HAVEN POOL c
CONSTRUCTION WORK SHEET
�I
Name: meJob
Address: (: S MondD te- au
City: Zip: Sal
Home Phone: )68) -77/ - 319 -17 Ma
Work Phone:
EXCAVATION:
Type:11&o,SS 4)'/D -In nemn#'4t nl ro
# 2 Pool Size: W _
Contract Date: WD14 Y Pool Depth: -3'15
esman: _ Perimeter '7a.
)/Page: - F12 Sq. Ftge: j� c)-!<
sl: n Spa ___---
TILE: -'Sill i40Pi
Trim: RBB:
5.. Sheer Descent
Spa Dam:
STEEL: A
RBB Surcharge
Love Seat: - -Swimout
PLUMBING:
Returns: �_#Jets:_Fillline: 4d, n .
Spa Run: Spa Lite: Pool Lite:_=tka&ra(
GUNITE:
Spa: Love Seat Returns: 3
RBB: Cup Anchors: 2 Fillline:_
ELECTRIC:
Ftg: �Pool Lite:,fin&J Spa Lite:
Smart Lite: Heater.. -Blower.
Jandy:
GASLINE:
Footage:
STARTUP:
COPING:' 5P"�
Safety Grip Waterfall
Bullnose:- Flagstone: Miters;=_
DECK:
Sq. Ft: D Type: 5a-6& _ Color.
Decco Drain: ? �Risers Bd. Jig: —
RETAINING WALLS:
Footage:
FENCE:
BH: _ z of OWNE
lj en "qn
PLASTER -
Color IJ%_Spa: — Returns: r'
Eyeballs: _Filline: �Cup Anchors:)efe,s
i
SPECLAL NOTES: ,
14,
EQUIPMENT:
Filter. P/ Pump: Ila H Pss Cleaner.' Heater --,
Board: Slide: Pool 4it'j, S±2nd, rri Spa Lite:=
Blower. Remote Control_ 3V '# it �r-n Color Pak:�ev
Solar Cover. Highlander Cover.. Chlorinator. ---Smart Box
Ionization: Sheer Descent—Y;77 SK t m vr77