0008-167 (RPL)ry.
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LICENSED CONTRACTOR DECLARATION
I herb'!y affirr�;�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
4834f9€1 B C55 � 12�31121r
Date .t 7 { ."- Signature of Contractors
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 14-901014 INSURANCE Policy No. WC3419-0599
(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
sybject to the workers' compensation, provisions of Section 3700 of the Labor
ode, 1;shallforthwith comply with,tllose provisions. , )
ate: »'%4 ' 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
theAbove-mentioned property for inspection purposes.
Signature (Owner/Agent).e?...0 Date>
BUILDING PERMIT PERMIT#
D E VALUATION LOT '�-TRACT
SISM0.00
JOB SITE
ADDRESS C":T.j COt,.1 IDROOK LAN
APN
;
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Ji"N \ BP_0WY MU' 4DO
PITRR,IWr POOLS AND CORSTR 3'017014
45-355 C>JI,T:3BROOKIANE
P,0, BOX 152A4
LA t UINTA CA 92255
PAtai!1 M�:EL T CA 92261
(760)568-4963 CBI -41 2
USE OF PERMIT
POOI, AA}NOR Sl'.A.
POOL &SPA ONLY>ALARMSIBAtxRIL:R.S SHALL B91N PLACE AT PRL
PLA.S'MR WSPECTIOW. POOL EQUIPMRN T LNCLOSURE IS NOT INCLUDED
114 THIS PERMIT
VALUATION 151000,00 1.9
ESIT MATED COS' OF C0VFJ1ZUC .9` O1q
a ,dl ,iii
PELT FWX gAWARY
PLA14 CHECK FEL 101.000.439-.318 $105.30
CONSTRUCCIGR11rit1; 101-000-41.8-000 $167.00
hfl' '-1r MICfiiL FFE -- F,POL 101f000-421-000 $24,00
FI,i.CTWCAL F92 F. POOL, 10'1 t ooI 4213-wo
PLUMB1NO M -- POOL, -101.000-419-000 x,00
AUG 0 9 2000
'ITS' Or Q,
l '
sm-TmXL f.:0XT113i:3C.raOX Alm :4yi.AW c iVX*,':i .
B FRE -PAM MV
O. Uta
TOTAL PEA Ii SDUE NOW
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
-INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE I
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
21 00�
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
Gas Piping
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
I
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)
PURRFECT POOLS & CONSTRUCTIofi RE-JNSPECI'tON RE Of 110
WILL BE CHARGED IF THE APPROVEI)
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR h SCHEDULED
INSPECTION.
NO EXCEPTIONSt
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
l IAIV 8Y a,
GENERAL SPECIFICATIONS
SIZE: �� x '+y
AREA: PERIMETER ZZ E7
TILE CHOICE sq. ft.
RBB: -Ir- \Z'�
COPING:
POOL CAPACITY GAL.
PUMP CAPACITY GPM
MOTOR HP
MOTOR HP
HEATER SIZE: / %S 000 4r4*
TURNOVER:
SUCTION LINES:
RETURN LINES:
SKIMMER MODEL:
CHECK VALVE:
POOL LIGHT
AUTO CLEANER LINE & VALVE
AUTO CLEANER
CHEM.FEEDER 1
PLASTER COLOR &.V;;r-
DECK SO. FT 300
DECK TYPE
STEP ff.
SPA SPECS
SIZE: RAISED
RAISED
LITE WATTS
TRI LEVEL SEATS:
DAMWALL x
DAMWALL TOP
SPILLWAY SIZE:
SPILLWY OPEN CLOSED
#JETSUPPER LOWER
NAME: r�+V1V��17
ADDRESS: k-� :SC -CS
CITY: 1 ,.,
TRACT LOT#
Contractor cannot assume responsibliity for damage to curbs, sidewalks, driveways, sewers, lawns, trees
fences, retaining walls, sprinklers, telephone lines or shrubs. When access, if made through a
neighbor's property, it is understood that you, the owner, have that neighbor's permission and assume
full reponsibility.
DATE: signature