9908-188 (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
ryrofessionals Code, and my License is in full force and effect.
License,#' Lic. Class Exp. Date
6146115'
.i OWN /M
r, ""...
/ate - Signature of Contractor ' t -=f---
c
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.
iii i 7Slf,t,'S
(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 all fort . "th comply N t(�qs provisions��.✓7
1Date: ;�#u Applicant-
Warning:
pplicant f �t�t.,.- "---------- -- �'
c:/
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. 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 prop6hy for
inspection-purposes. "
,,Signature (Owner/Agent) ✓ y_ ,Date
BUILDING PERMIT PERMITk
DATE faimit"VALUATION $t141H4AK).f0 LOT TRACT
JOB SITE
ADDRESS 79-&15AV�t"�Pg3�1.�ic'�R.t&i:IA.
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
7 /�Sa!% t � t�f' t ie�f� 1
t r` r 4. i>"l, J 4Yls �.f
A •7f jI'.�T'�ri? 7:' �t �r�i ?' (�,., t 7J ti 4
1'6L.A•1.Y !. P 44f., P t d ..i�1 M1ILr wail. i"?.-
50-930 A v'ENIDA NA.VtWA.
P.0 . i0 .X 1791
LAQ#irPt`!A. P'A 92253
LAc,tVINI.A" S,'.A 92233
",'Lfj.ei V)45
USE OF PERMIT
S'l3�)�. a�.+i r','�A�'i� " .raS.t�'14i.�'f:9f'.1•x�$�.44Yi i+�.7-:A7.1�n La ei �� L�4r: t\rL, %�1 .R.'�Q�i .
a�4ieiri..ra�.%
11 MINIM
,�y}� 7, j� ��'�� Myy��ggyeyv�.'�r.°1:�.ivi'w'3i°.i
PLAN r('HRC K SA?S.N)
(Y)NI:TRI(C'iid>Nr0-". fill-#!d)f)-418•-i}K) ?imxnn
&2r3(".�31'irriG"�;t. ]C#1- ' ��r:s✓ L 1.flI-WO -125. GV 42A.00
L,LL•C t'R,K-!,AI H�i -- a ;.i #.til
4PL? 3 tf511'ii � htl3. 140"OL t il'# -?.Y,M-41,!- S211 till
h# 1Fi- l(f €'A I�, t f:�ti' )r(It "iC)Pj �ltii➢➢1.1 t `)i!'�t
!
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs t
Underground Ducts
Forms & Footings I
Ducts
Slab Grade t
Return Air
Steel i
Combustion Air
Roof Deck {
Exhaust Fans
O.K. to Wrap q
F.A.U.
Framing i
Compressor
Insulation q
Vents
Fireplace P.L. I
Grills
Fireplace T.O. ;
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath 1.
Drywall - Int. Lath 9.
1
i
Final
Final t
POOLS -SPAS
BLOCKWALL APPROVALS
steel
Set Backs 3
Electric Bond
Footings [
Main Drain
`
Bond Beam q
Approval to Cover
t
Equipment Location
t
Underground Electric
[
Underground Plbg. Test
Final {
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines t
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out }
Equipment Enclosure
Shower Pans (
O.K. for Finish Plaster
Sewer Lateral q
Pool Cover
Sewer Connection q
Encapsulation •
Gas Piping q
Gas Test }
Appliances q
I
Final
Q
t
COMMENTS:
.-
N"
I
c
Final {
Utility Notice (Gas) t
ELECTRICAL APPROVALS
Temp. Power Pole i
Underground Conduit
Rough Wiring i
Low Voltage Wiring t
Fixtures I
Main Service t
Sub Panels {
Exterior Receptacles
G.F.I. l
Smoke Detectors q At
Temp. Use of Power
E
I
Final _, t
Utility Notice (Perm) I
MAIN LINE
U SKIM"MER-MODEL
BACK ASH TO
' OF Irr FILL UNE
ANTI -SYPHON VALVE
z/ HEATER v( -e SIZE TU
GASdUNE BY: VENTED BY:
LIGHT CC (, ♦ (t/�
CL/OCK Qv
G.F.I. BY:
)�
/ELECTRIC BY: M
V
ILA 1.11 /T 'lL 7 T1 T
two ("T ■ 1V ■ V K on
tell\LJ
iTY OF LA I�
JILDING & SA ETY rPTT
APPRO ED
FOR CONSTR CTION
TE (a BY
i
i
CONSTRUCTION SPECIAUST
76o360-3585
i
I
GENERAL SPECIFICATION
SIZE 13A_ AREA So
OEPTH3 TO_jj"
SHAPE cusloba
PERIMETER IqO
TEMPLATE NO.
CUSTOM
TILE SIZE
TILE COLOR
COPING
COPING COLOR
POOL CAPACITY
GALS.
PUMP CAPACITY
G.P.M.
MOTOR H.P. (� S
�/ j H.P.
FILTER
6Q SO. FT.
FILTER RATE
G.P.M.
TURNOVER
HRS.
VACUUM UNE i SKIMMER
x
RETURN UNE
MAIN LINE
U SKIM"MER-MODEL
BACK ASH TO
' OF Irr FILL UNE
ANTI -SYPHON VALVE
z/ HEATER v( -e SIZE TU
GASdUNE BY: VENTED BY:
LIGHT CC (, ♦ (t/�
CL/OCK Qv
G.F.I. BY:
)�
/ELECTRIC BY: M
V
ILA 1.11 /T 'lL 7 T1 T
two ("T ■ 1V ■ V K on
tell\LJ
iTY OF LA I�
JILDING & SA ETY rPTT
APPRO ED
FOR CONSTR CTION
TE (a BY
i
i
CONSTRUCTION SPECIAUST
76o360-3585
i
I