9610-013 (RPL)U)
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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 Sectiq,r.7004#of Division 3 of the Business and
Professionals Code, and my License is in full1orce and effect.
License # Lic. Class Exp. Date
Date 0/1' q& Signature of Contractor `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
T
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^i'stsNGe ly'Qrkers' 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 Secti n,3700 of the Labor
Code, I shall forthwith comply withfth,ose provi's'ons.fjl
Date: 9 ! Applicant F�JCg r'
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
o-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 property for inspection purposes. �y
Signature-(Owner/Agent) �' Date Q -
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PERM' N����+T°NTR°`"
BUILDING PERMIT
4,17 7
DATE VALUATION $14-5410.4„) LOT TRACT
toJOB SITE
ADDRESS 79-2911 r.r"`4.1<NO 11"0S AIM APN
OWNER
1: y5 ISO u S1'
t+, R
000.'�K I -&)07
USE OF PERMIT
KA)], AN010104'A
POCK. ANI) SPA, C. NLV
CONTRACTOR/DESIGNER/ENGINEER
tXl10:{;1RAI-t:`J'CY CA '42234
fell9*0211-12:12 10"
IIf,RAI 11' Fills; NIfiN1M AKV
1-11INN 4 "fiP.C`b; i'FF, 101.4iG0439-:3114 S l.bti. �ti
-Oi�.'9TRf.;C1'it:l FEE 101-cft-118,000
P10Ot, 101 -ON -421-000 37rf,inl
KLI3C f111CAJ_ P131H, -- P60L 101.000-41120 AX) S45!, f)
M:i)lLiS3lWr'FRE --P() ,. 101-ft)-4.1q-41ZJfi $27.00
SUS-'1"MAL CONSTRUti..'"C ON ,AND PIAN C11T'CK
LESS KE-IiAll) PC-' ES
AL PERMIT VENS DUC 'NOW
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
14,500.00
$363.30
$0.00
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
F,,eplace P.L.
Grills
`Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
P6,,ty 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 -099
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Fr.
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SIZE
RAISED 6" '
LFE N WAT—S
T=t LE%/E_ SEATS
22' 24' ?Z' 6
DAMNVALL '61DTF
SPILLWAY SIZE 6 x 12
SR'_LWA
OPEN X C_GSED
# JETS 4
RL
SIZE y' y `xy 8 YAREA 252
DEPTH 3,E"XS'X316"
SSP° PEIL'IIETER 74
—TLE S -Z= 3X3
—
-ILE C—B,SOLO:
COPING 5�hT --
COPING COLOR TBS
PIRA- C"I%C-Y 70f10
3AlS
PJNP CMAC —Y 90
GP%l
t/OTOR -tP 5TARl 1.5
FILTER S AR17E 30D Z
FILTER PATE 100
GP%I
-JRNORAQ Z HFS
kx-r cri LtVfS + _
FEW -IN _IVES 2
%tAIN JRAN 2 .
S<R MODFL DUAL PORT
CHECK VALVE )'ES
HEATER -4AIS .SZE250;00an
G4SLINE BY SDC _
POOL LIGHT 40t: VIATlr
SPA -_IGtiT 100 WA i T
C_OC< G,C(Jv
ELECTRIC BY S�i7.c
ELECTRICAL BDNDIRG 6Y: S-QI
TLE ANC OJPING &QC
DECKING BY SEC 562 5Q FT
! DBUFF COLORED SALT
I CONTFACTOR canna assume
respoisibirty for dam aEe tD
curs, side. -calks, dr►✓enaJys,
cement slabs, se✓rers,
lawns,trees, fiervxs' re:aiiiig
walls, sprinklers` telephore lines
or shrubs. *Whei 2coess s mace
through a neighbor's prcp=_rty itis
ESIGN understood that you, the Avner,
have that neighbor's p"rmiSSion
t�tvv--q _ an:; assume U res-consloiity.
g_mg�wlr a u� r
dress: 79-2'90 CAMWO ADS"
Cyt f" LAQVNTT
7p RANCNO 00077Lw LOT# 84
Dodsom
pots
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