0104-124 (RPL)PLICENSED 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
656121? (33 MC
Date 41 , Signature of Contractor , ' � j
ldf
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.
Se( ctiI_have and will maintain workers' compensation insurance, as required by
on 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 provisions-
Date: 1 e r , e.10 Applicant +
Warning: Failure to secure Worker's' Compensation coverage is unl
shall subject an employer to criminal penalties and civil fines up to $1
addition to the cost of compensation, damages as provided for in Se
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building anj Safety+
for a permit subject to the conditions and restrictions set forth on his
application:
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
'I'certify. that I have read this application and state that the above information is
I agree to comply with all City, and State laws relating to the building
1;construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purp ses.
`Signature (Owner/Agent) Date e�'
BUILDING PERMIT PERMIT#
DATE / VALUATION LOT �" �•+�"� TRACT
JOB SITE
ADDRESS
APN {
431 W15 1. 10RULNG A AIR
OWNER
CONTRACTOR GEER
.�r
(MINTUi6, ryy0.Mpa11111 L4aLyITTE�L1
ytgA POO.LS uUPAS, (ro�p NIM o
4ALH1Ia1
1 305 no, TO ITgid ; S��, 411200
7.4725 JOH1: ME'effl, SUMS. 4A
S IR 3 EMNA RDWO CA 9.2, 013
PAJ:.PdI Y)&1MZT CA. 92260
Q60)340-%= CMIN 3;15
USE OF PERMIT
' POOLANI OR VA
XXXASPA.. A1.A a YiT.rzM10 i SHAW, AL fN PIA C.1,? AT PFt E-PLAS'FE-P.
WN210—TIO N,001,.NU3P1?E.+�1IT MCIA?OURE h$O1' INC#,t:MI),
POOL A1d��i�3R SPA l��:3D:r311 1A19
NNITMAIM) COST (IMP, CONE"'NUMUM
MAN CHECK VRE 101-000-439r-318 $32%70
s:3Tf�'6kki'`lIA%3k 1d?I-lal;�i�RiE2 (3f?D19f%Qt1
;MIRCHARIC„A11 F •- P -00L 101.000421.1000 $7114.40
. `, Fr -14 U199 1. L 101-000-4,20-000 $4s,60
�64�A�l3Ftri�l.T'�1�-•'. ..� '!t)1��1�?Op�•1�nC1f1EY fa��.ilfd
APR 2 0. 2001
CITY OF LA QUINTA
FINANCE DEPT
S -` 7AL C`,:O1�i"M`R1'3Mt` N AW :D X" C'Mt^.I
$422.100
RECEIPT
DATE /�
BY
DATE FINALED
INSPECTOR
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Test
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FixPires
Main Service
Sub ALnels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
OV#" TO- Al rArrPW%ftV -ftV APPROXIMATE ELEVATION ~ &^ft OR SPL AT a &Y^ W ON DAY OF EXCAVATION
(Z TAKE NOTICE THAT POOL AND EQ M"W LOCATIONS AM SU SECT TO A64EPTANCe OF LOCAL ct=
LOCAL 9ULDIN6 DEPARTMENT AT TME OF ISSUANCE OF P5W1 I
(3) PIET POM CONCRETE SHELL AT LEAST TYWZ DAILY FOR SEVEN DAYS AFTER WU 15 INSTALLED
(4) AORM 7►IAT CALIFORNIA FOOLS 15 NOT RESPONS!" FOR VVERSRO" CONDITIONS OR 00JIV.75
AND ANY VAMA&E TO CLIRISS, S(DEFM", DR WAYS. LAYM OR VT#et IT" IN T#C A"155 AREA
(5) SEE THAT ALL PENCIN6, BATES. AND OARAM DOORS MEET LOCAL CODES FOR A POOL ENCA.MM
PRIOR TO PREPLASTM INSFIX-TION al
(6) FILL POOL 1140MIATELY AFTER "TER. "LEON INSTRIXTIONS - DO NOT USE RAMM NOW
('T) TAKE NOTICE THAT TMS DRA"NS 5 THE SOLE rR0P!Rrf Or CAUPOWA FMS AND THAT ANY
USE Y4lrAOVr VftTTEM PERMISSION OF CALIFORNIA POOLS, INC. 15 PROHOITED 15Y LAN
O"et APPROVES M -AN, POOL. AND EC ",I!NT LOCATIONS AM MS WAD THE RESPON50LITTES AND NOTICES
SIONATURMS) DATE
5iNIMMIN6 POOL PLAN FOR:
NAME
RESID
COLEEM."";1E
-WAIC
'L- > T. -1
STREET q7- S --:;-S- 1"forml-41F, I
JOB ADDRESS S-rr,.j<CITY L^ QJ(AIT-.o\
PHONE OFFICE RES
LOT 3 TRACT PAGE BOOK
MAP BOOK PAGE NO. ICITY
MAIL ADDRESS
CONSTRUCTION OFFICE PHONE NO,
SCALE DVE DRAWN By SOLD BY CHECKED BY
I 1 ZZ --REVISIONS DATE
2
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31
41.
SELECTIONS
STONE L,
(4
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BOULDERS
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JANDY Sm -19 T- TnQ(c-)-)4AO—Tz--
PEBB./PLAS 4,K'-- � Y n e- j
SIGNA TURE
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GE NOTE:
others, unless otherwise. noted. y
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(Z TAKE NOTICE THAT POOL AND EQ M"W LOCATIONS AM SU SECT TO A64EPTANCe OF LOCAL ct=
LOCAL 9ULDIN6 DEPARTMENT AT TME OF ISSUANCE OF P5W1 I
(3) PIET POM CONCRETE SHELL AT LEAST TYWZ DAILY FOR SEVEN DAYS AFTER WU 15 INSTALLED
(4) AORM 7►IAT CALIFORNIA FOOLS 15 NOT RESPONS!" FOR VVERSRO" CONDITIONS OR 00JIV.75
AND ANY VAMA&E TO CLIRISS, S(DEFM", DR WAYS. LAYM OR VT#et IT" IN T#C A"155 AREA
(5) SEE THAT ALL PENCIN6, BATES. AND OARAM DOORS MEET LOCAL CODES FOR A POOL ENCA.MM
PRIOR TO PREPLASTM INSFIX-TION al
(6) FILL POOL 1140MIATELY AFTER "TER. "LEON INSTRIXTIONS - DO NOT USE RAMM NOW
('T) TAKE NOTICE THAT TMS DRA"NS 5 THE SOLE rR0P!Rrf Or CAUPOWA FMS AND THAT ANY
USE Y4lrAOVr VftTTEM PERMISSION OF CALIFORNIA POOLS, INC. 15 PROHOITED 15Y LAN
O"et APPROVES M -AN, POOL. AND EC ",I!NT LOCATIONS AM MS WAD THE RESPON50LITTES AND NOTICES
SIONATURMS) DATE
5iNIMMIN6 POOL PLAN FOR:
NAME
RESID
COLEEM."";1E
-WAIC
'L- > T. -1
STREET q7- S --:;-S- 1"forml-41F, I
JOB ADDRESS S-rr,.j<CITY L^ QJ(AIT-.o\
PHONE OFFICE RES
LOT 3 TRACT PAGE BOOK
MAP BOOK PAGE NO. ICITY
MAIL ADDRESS
CONSTRUCTION OFFICE PHONE NO,
SCALE DVE DRAWN By SOLD BY CHECKED BY
I 1 ZZ --REVISIONS DATE
2
z
31
41.
SELECTIONS
STONE L,
(4
TILE
BOULDERS
DECK COLOR 04 F-,'zr. OT tJ 4 L rli�t Lt.)
JANDY Sm -19 T- TnQ(c-)-)4AO—Tz--
PEBB./PLAS 4,K'-- � Y n e- j
SIGNA TURE
DRAINAGE Drainage and irrigation for planters and pots, b
GE NOTE:
others, unless otherwise. noted. y
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