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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
(5i.4611. C.53 Y3 ,991
/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).
( ) 1, 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.
C�,A� EWDON NAl'I(Y, 011 P,0t)0;,I40
(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 a,911'161,fety
for a permit subject to the conditions and restrictions set forth, n his
application. /(Y
1. Each person upon whose behalf this application is made & each person at
hose request and for whose benefit work is performed under or pu gnt to
permit issued as a result of this applicaton agrees to, & shall, nify
& Id harmless the City of La Quinta, its officers, agents and emplo ees.
2. XDy, permit issued as a result of this application becomes null an01void if
work is not commenced within 180 days from date of issuanc touch
permit, or cessation of work for 180 days will subject permit to cae ti
r7con.
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 PERMITi�-zea CONTROL#
DATE VALUATION $211,tJ400 LOT TRACT 834
JOB SITE
ADDRESS 79-800 RE, AIMltVGTON DR
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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":Cl"PE"Y ' NMI,` & SPAS
120 CcIL.LE' V. 1 ,,W 4206
11.0. BOX 1791
i,A QU191-A CA 92253
1A QU1NTA CA 92253
USE OF PERMIT
N-K)L a%l+jDuk SPA
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POOL tt SIVA ON1.1% ALARMS S AiNI)/Citi I3htti LER kt~c7i3iliED FOA
f'kia-_I'1.A:�.i'�t 1N5YiUC'I'1t31V
PAIL)
OCT
15 1998
pOU1. AN�i:G,� SPA^tl,tlQf►.f}ti i,..
✓I OF
LA OUI `TA
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ESTIMATED MS 2' OF CONSTitll ffION
20,0f woo
I';N:sgdll'CI3' D{ iL,l�; 4iJ1k�M:1lR�i
Sri.AN C'WA,"iC FEE 1.01-000.439-318 $1M.55
C:n7, NTR_1T(`.'k ON F!iE 10141lM-41.8.000 t?fl'7 W
h1F.C11;AMICAL FiE- POOL t01-0004214100 $21.00
F:i,F.C:TRICAL FHE -- POOL 1.01-(i00420-000 $45AW
PLUMBING FIT. . -- PC X_)L 101-0(i0-419-000 327.Ui1
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suB-7r)"114, com") ;'V: "DON AND PLAN C141:OK
S437. -is
LESS PRE-P.A11s FEES
$0.00
`i'0'l•fFRA11T FCK141iiUE NOW
$437-515
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
K
INSPECTION RECORD
OPERATION DATE I INSPECTOR
BUILDING APPROVALS
OPERATION DATE p INSPECTOR
MECHANICAL APPROS
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
I -//., _;
Set Backs
Electric Bond
1011 tg_
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Zo - lG
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Z T16
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
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
i)tilRy Notice (Perm)
COMMENTS:
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
POOL AND SPA PLAN CORRECTION
DISTRICT # %' a` PLAN # S� 0 J�3—
DATE /0
PROJECT NAME ST � r � �+ PROJECT LOCATION
OWNER/CONTRACTOR r S 80 /b s
The plans are now approved subject to the conditions listed below:.
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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 INSPECTION, and "APPLICATION TO OPERATE" has been completed and PERMIT fees
have been paid.
REQUEST FOR, FINALINSPECTION SHOULD BE MADE AT LEAST FIVE (5) WORKING DAYS IN ADVANCE.
,
PLAN CHECK BY �1 (/ Phone(—) d (f3 P7
I acknowledge the corrections noted herein and as indicated on the plans and agree to incorporate them during construction:
Signature
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Company 4i /'Ecol S '4 S�
Date
DOH-SAN-181(Rev 1/92) W -OFFICE — Y -APPLICANT — P -BLDG. DEPT.
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COUNTY OF RIVERSIDE HEALTH SERVICES GENCY
z„< DEPARTMENT OF,ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # '' �""� c� `,{0 �a"'� �P DATE /O l I U
SUBJECT PERMIT Nb.',
ADDRESSO
INSPECTOR
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