0203-050 (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
Professionals Code, and my License is in full force and effect,
License # Lic Class - - Exp. Date
a3.liti C 33 / • 'bi 31/20(
Date �` !Signature of Contractoir �A
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 �A• 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 Section 3700 of the Labor
Code, I shall forthwith'comply with those provisions. �� ,
Date: L 7 h Applicant I—P7441--
�
yWarning: 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 t6—
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 wrk 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 propertyfor inspection purposes.
Signature (Owner/Agent) Date " 7 �p
PERMIT #
BUILDING PERMIT
Ete+c3-c�
'LOT AC
TRTJOB
DATE . I
! fQ VALUATION �i } lyiZlili,fl
ADDRESS !8-5.191 VOMIP5`rl�! COUR� -'
APN .609-070-Q38'
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
I"nwl 'Ji— 1k r��r n y-rn9.f ISr 1r,°
�✓J'a, i.Atd. {V.J.6:1,)
78-615 NAMES DR
93M DDN1YV i ),9C)N i D. -
t,AQIJ€N A LA 92253
►.iJ4:CE2NE VAILLE r. "CA 92156
'
«60)24&6045 t ►It,F1- del,95
USE OF PERMIT '
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Bond Beam
Main Drain
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
Sewer Connection
Pool Cover
Encapsulations
�U
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
Utility Notice (Perm)
COMMENTS:
—.-;-
A RE -INSPECTION FEE OF $30
_
WILL BECHARGED IFTHE APPROVED
PIANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCMONS1
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
GATE BY
—y!&
lam- O 1
ph-.
�8Sjl Pompet/ /__ j+ (9L) r STA
VACATION POOLS & SPAS
9522 Donaldson Road
Lucerne Valley, CA 92356
ke
(760) 248-6045
(760) 248-2919 FAX
Lic. #C-53-351673
Sales Locations
Bermuda Dunes, Irvine,
California City, Rialto,
Lucerne Valley
1 800 999-1811
SIZE
X j-6 '
AREA
PERIMETER
DEPTH _3/_&/
TILE CHOICE
SQ.
RBB.
COPING
POOL CAPACITY
GALS
PUMP CAPACITY
GPM
MOTOR HP
HP
MOTOR HP
HP
FILTER
SQ FT
FILTER RATE
GPM
HEATER
SIZE BTU
TURNOVER
HRS
SUCTION LINES
CHECK VALVE
GASLINE BY U. P, FT.
POOL LIGHT Y -e.-S CLOCK k t5
ELECTRICAL BY V. 0, FT. A,i±
AUTO CLEANER
CHEM.FEEDER
PLASTER COLOR
DECK BY t9 %► vs SQ.
DECK TYPE Get. ^i-,,
SIZE lc `/.ZA& *./RAISED l "
LITE e - WATTS Zoo
DUAL L VEL SEATS
- DAMWALL (o
DAMWALL TOP I
SPILLWAY SIZE a." X G " WIDE
CONTRACTOR cannot assume responsibility for DATE SPILLWAY erS
damage to cubs, sidewalks, driveways, cement #JETS S'
slabs, sewers, lawns, trees,jences, retaining walls,
sprinklers, telephone lines or shrubs. Name: Cat U- v -p `
When access is made through a neighbor's property
it is understood that you, the owner, have that Address:
neighbor's permission and assume full responsibility.
CjjXj 1,
DATE SIGNATURE �� S a- TRACT � l
✓ LOT#