0010-160 (RPL)H
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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
s i 3*ttt C°53 i3 1: �:11AI
' � ' 1, a^ rµ � r �..
gate Signature of Contractor
U
OWNER -BUILDER D&LARATION
I hereby affirm under penalty of perjury'that I am exempt from the Contraddes
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&RC. 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.
•,( a' 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:
Cartier Policy No.
CREDIT 0049RAL 04
(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,
1 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 will those provisions. .-
J Wate: ,+, ,.: , ? ..�,ilApplicani" ;,. ,
Warning: Failure to secure Wfirliers' Compensation cove'r4ge is unlawful nd
shall subjectan 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,"t
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 a
permit, or cessation of work for 180 days will subject permit to cancellation.
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 property for inspection purposes.
�Ignature (Owner/Agent)} r`." r' ' pia f•'i Date) ? y
BUILDING PERMIT PERMITM
DATE', ,' VALUATION LOTTRACT
920=1303
JOB SITE k
ADDRESS
JAPN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Mk JAC-L)BUEEW
CAT 'Tr'. A11" UIC P'OC,LIS
S017 LAKE 1M. r L,NE
1110, BOX 1804
BELLEVUE WA 99006
Pr'�.M3iP�+.A2.1OS �`,.�i�p92263
(w.))322 -'?782 L..Luit 6219
USE OF PERMIT
POOL 11�.ID/r,''R OIjA
1~ OOL&F'A ONLY. EiI. ARM,"JISARRHERS SHALL RE IN PLACE AT
t"RFr.PL,AIO"TFR H43PECTIOX. I}OOL, Vie?mPtv4xm,r h.EdC:wq(.I.t?ti:.Is Pfar
54 w'L.'O DKI).
FC?C.i 1" AJ.3'iVOR S"k'.Ea :3(1,000.4b )18
+�OYr OF C01118'k7MMI+ON
201000.00
y,�,yyp �' AA qy��p. Qp7 k� N� q:�:ySy"Y'lAUiD
111.,A14 CHECK RFP. 101.000.439.316 $134. 5
CONSTPUCTION PRE 10i-4045-4141100 $267.0
><a11Psi;I LMCA VEF -• POOL 101-000-421-000 S?4.00
FUUL't RACAL FEE •.a POOL 1101-000420-000 $0.00
;PLLfMAY?R3 FEE •- POOL 101.000419 -ON $27.00
r
a L Tf�L>;_ONIS" RUCTION' /4g!) PIAN (,-.H ;CX
T43 7, 3 5
` LR3 PRE -PAID JW3
$0.00
T(Y..W,11'11 RMIC FEES 1:WE iYOW
CJ Z ,
4$437.55
a
of
RECEIPT
DATE
DATE FINALED
INSPECTOR
, 17
j
NSPECTM [RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
S ULDNG APPROVALS
MCCG',IA6l9 CAL APPRO AL S
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
_
FOOLS SPAS
--
DLOCKffALL <U P—PROVAL
Set Backs - e --
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Lacetion
Final.
-
Underground Electric
Underground Plbg. Test
Gas Piping
_
'T� LDAr0� ","G 1. IPFRO A �
Gas Test
Electric Final
Waste Linos
-E
Heater Fincl
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
O.X. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
!
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECYMCAL 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
Final
Utility Notice (Perm)
P.1
Nov 14 02 09:13a
V
Vtl�1 TY OF LA OUINTA
BUILDING ✓;r SAFETY DEPARTMENT
of FN a,0 777-7012
` Z INSPECTION REQUEST LINE
of MPT 777-7153
I MR. JACOBSEN
ner
Contractor. CAL PACIFIC POOLS
Permit Number 0010-160
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
5�-%530 CEMM MELS
JOB ADDRESS
POOL/SPA. ALARMS/BARRIERS SHALL BE IN PLACE AT
PRE -PLASTER INSPECTION. POOL EQUIPMENT
ENCLOSURE IS NOT INCLUDED.
TYPE. OF INSPECTION GATE INSP.
FOUNDATION & SETBACK
PRE-GUNITE I 7 >5)
DO NOT POUR CONCRETE UNTIL ALL ABoVE.:HA&BEkN SIGNED
JOISTS & GIRDERS
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH GASB GAS TEST
HEATING ✓li VENT - AJC f --
FIREPLACE
ROOF f —_
BOND BEAM
GROUT 0 4' O 8'
FRAMING
UNTI
EXTERIOR LATH _
POOL PRE PLASTER
[SFW
COMPLETED
ALL CONCRETE FLAT WORK SHALL BE PLACED A
I911INIM.UM OF 2" 'BELOW WEEP SCREEDS. o