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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
C53 00, 1013 1 4c,
Date l/M* f 61,/ Signature of Contractor_ f ✓�°� E�
;0C.,
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).
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 Labo& Code, for the
performance of the work for which this permit is issued.
(y) 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 �WAT9C<4.7M1� 3,1r.ATa Policy No. WHOM
(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.
1 Date: ,Applicant ,P
Warning: Failure'to-�secure ,Workers' Co_mpen ation 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
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.
i Signature (Owner/Agent) ".. Date a _
BUILDING PERMIT PERMIT#
'
DATE VALUATION LOT pix . TRACT
JOB SITE -
APN
ADDRESS - • �us (,,OURT»
OWNER
CONTRACTOR / DESIGNER / EN &NEER
fu EaTURY MC3V'I.If" U , C OMMi dNN16S
CALWORRIA, POOLS & a �kg (o )P N9A3:3' C01
1335 so, 'I'D" M.Wrl, 1912111 1W200
74725 �TOIU DRIVE, 11A
X&T BERKUSI RDINO C.A . M08
PAZIM, 7L`+1i ►id Irr CA 92260
-
3403 9000 afti ., 355
USE OF PERMIT
C"d:tMPAIMCIAd1 POOL ZE ,SPA. pNM.A1,AR:t S/k3_A;liR1Ma "SNALL BE IN PLACE
"NoLOSuRR BS NOT
Tf:1CL# TU'r) M THIS PAR -MIT
POOL ANYWOR SFA 11S
1C�M"U.:D 'L...W/!,`I A �„! 01 bS7NS11AtbU+.N�S.B.b•1+J•\
.C'.CY4S�6YS..rVFi'
y �,µy er' g�
UMMARV
010 t kOCrK FYIE M -C>0 -439.316 $176,48
C:f:;:1P:.'1 RIUC'i'1M IrEs 161 _000 31 B- IWO $2111,%
M"trMMIiCALFE1 —P001. 101,0004',11.ObO 124.00
KI i(',C:TRiekt,1W.:. BOOL 101-000-$20.000 $45.00
De
OCT 0 2 2001
CITY OF LA 011INTA
FINANCE D:PT.
�,( T0,1ALCONFIFRUMONAM PLAN MEM
$543.98.
$0,00
TOT
'Ail NOW
RECEIPT
DATE y
BY,
DATE FINALED
INSPECTOR
P",
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
Fin 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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Teml- Power Pole
Undgground Conduit
Rou6ti Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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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
61 i 45 VIM C513 FAC CI'S 1 W3 112(
Date Signature of Contractor
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 "�'i'.r T# CYCJ ►; 'f A'tF Policy No.
MOM
(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: Applicant
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 property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# co"
DA VALUATION LOT'
-a,�7ia,�a
JOB SITE APN
ADDRESS w.Awry cmumn;Fi� . mum,
OWNER
CONTRACTOR/DESIGNER/EN INEER
t: t"��u3/'.��' Y C_R11) )T J.:q
'Cry.'�AL.%�q*�'���:E,wg�F,nPt�.q?,fy��I,JS� CrOP MAST C0.1
{"1-)i y�[�.}:'�iL.,�.gt���ni)�:f�,l�;g��J)�
:1535 so, TO U (1. MT. L71 rL'n 00111 0
�&pSv�4j�1rd1J
fell ✓ �. ONI 1)R- .Y.F',p fJ� ]"YB` A
°+SQA DERAVA7 DT -4'0+ CA 97,408
PALM 8.) �" , ,T CA, 92260
Q60)344-9000 CW355
USE OF PERMIT
C6 YN42AMC.k.T
C0*,1 ;ZPC,'ALL Pf"dCT? & SHALL art I'm PLACE
TUC'A5U'fr7�'.d:t• .rN THIS PMMIXT
F004_1,t��Pix t ,E� a . a�,trU . r I's
MAN CHECK MIS, 101.009.1439-318 9176.48
C0Mr5''a'>xf.l rCT.?C37N �^>+ l: 101 - 000-:9.18.000 17111.16
WICHAV3CAL FRE .- FPOQL iiia -000-421 -000 %24,:10
EL..t4�C;'1'R6+< 6kL F= -- P(X Xo 101-000-420-000 $43.00
i -b GJ `.14Y.k.^la.. 4oi✓d'ia?xZ'Z'kl .s �,aAM ♦ ITO P-pIN.4y3CK
5 54 9f
33 :ARE -P AU) S' 6
$0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
_771
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
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
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
_ _
�j�f�- �� A0d
COMMENTS:
7-
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
Final
Utility Notice (Perm)
i. , �•F ../., -r -I�•�« �:..�f.., r.... ��'• ..,-'�;-.';-..^"'k-'."'i'w..M"��"��rw'x11'i',r.jlt.d'tum''i+'�."y��'wl'`�r:'P...-.::S4rM't�Yr.' � •�:an V�i-?'�`frv�,ir.'`,;R''-r..ra+--..p.4r�r'.
r'
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
District Environmental Services Division.
POOL AWPA PLAN CORRECTION
District No. �-3 Plan No. Date �i ( /0
PROJECT NAME r✓t/pi5� r �-Jolo� U -.
PROJECT LOCATION
OWNER / CONTRACTOR iL:. G� r • ( ,(
,YJ o� S a v �/ o n� ��,( � l
The plans are now approved subject to the conditions listed below.
0 Grk 1Q/� S"l,rtrnlA� nvP �t GC w� �O/toi
-P D` (A r✓ dee c rC' c o f r C cl -{- n r- cY - x3f (n .
ti
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CONSTRUCTION INSPECTIONS: Contact the Plan Checker for pre-gunite and pre -plaster inspections at least three (3)
working days in advance.
A FINAL INSPECTION MUST be made upon completion of all'work including fencing, safety equipment, and signs.
APPROVAL to operate shall not be granted until the facility has passed the FINAL INSPECTIONS and "APPLICATION TO
OPERATE" has been completed and PERMIT fees have been paid.
REQUEST FOR FINAL I"4a—
NSPECTIO. SHOULD BE MADE AT LEAST FIVE (5) WORKING DAYS IN ADVANCE.
Plan Check By 6 t Phone (� � 6 ) e,- O -� �- 7
I acknowledge the corrections noted herein an s indicated on the lans and agree to incorporate them during construction:
Signature C•
Company (-�(l nJ✓��� lS
Date 9-12- 2eldl
DOH -SAN -181 (Rev 11/95) Distribution: WHITE—Office;
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