0206-197 (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
7 ,fib ! / Ct51:31�Zt
Datefln- t -/1 Signature of Contractor Y r�r �'• - � �' yvf
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 T110 ) IMANCR Policy No. W<_;=ri 02.1211617
(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' compensati6n- provisions of Section 3700 of the Labor
Code, I shall forthwith comply with ;hose provisions. :� t
Date:f it _ ?,Applicant
{
Warning: Failure to secure Workers' Compensation kcov rage`"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) IM,Q t�."Date6
v f°
BUILDING PERMITPERMIT #,��
DATE °'' 'VALUATION LOT TRACT
JOB SITE
ADDRESS �.• 1 E��i < �JxS.�iu
APN
OWNER
CONTRACTOR / DESIGNER/EN 1NEER
.
Ry ��, 11YpplER8
4R4RLCIgV19,11 CO{LZ
PAIIALSPRUXIS3 CA 92267,
USE OF PERMIT
POOLAND/ciao. SPA
PO011S A, Ai.P.1`.FV1;;l,8ARRIERS SHALL BE IN PR10:t o
1aHIPL,A3'1`ER INSPEC1110:4
POOL, ANDiOR SPA. 1.VU00 Lull
l.diw, OT, A,il—M27R4.T'3r•b,100
ME SUMAMW
PIAN CHREC,K ,FEE 101-004 390-318 18 2,1.1, 0
CCXA'S'33AJCTION;ir1! P 01-000-41.5-0 0,, $3710
MECHANIACIAL RX, _POOL 101-000-4,21-006 $24.60
1piM1:'S:T'l:.MAY.,1+ ft, — P001, 201-000-420-000 $45.00
PLUMli:rINO MIR, •- Poot, 101.00" 19.000
DUE, NOW
LiON 2 bLUUZ
CITYOFLAQUINiA
FINANCEDEPT
RECEIPT
DATE
By,t=
DATE FINALED—
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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 - S AS
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
9
Heater Final
ater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Zj
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
M
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760-778-2740 760-320-3667 FAX
z STATERS RESIDENCE
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'1-320 Avenida Juarez
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,a Quinta, CA
7
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In
GENERAL SPECIFICATIONS
T21SIO1S:
POOL. SPA
Length:
19'0'610"
Width-.
14T. 510" �
Surface Area:
2-0 SF 1_2 SF
Perimeter.
90 LF 38U
Depth:
3'6' to 5'6' 42" MAX
L
M
ISMS:
Ileckng:
Not Included
CD
rd e:
Tile Choice at Water Line
m
Dam WaA:
Spa @ +12"
CO
Dam Wall Spillway:
Tiled
LD
Raieed Bond Beam:
15'@+12"
Piaster:
White Plaster
m
JIPMET'Y:
LO
pump:
HRywardNorthstar 1.5111
v
Kilter:
Hayward 300 Cartridge -type
` 4
Heater.
Havward 25Ok BTU Ix-Nox
N
Controller:
Not Included
CD
Cleaner:
Not Included
CS)
Pool Ligbt:
1 ea. 400 Watt
a
Spa Lgtlt:
l EE 100 Vl'ett
04
tD
m
G&E
styes line
i0 5omee� 5'kFE�j"
P!L
S16 `5�—
I_a
19U
Aff
. I
I------------- - - - - j
31.1e
PA -1-10
PETE WATERS
51320 AVENIDA JUAREZ
LA QUINTA, CA.
849-E7
I
2295 East Tamarisk Road • Palm Springs, CA 92262 - License No. 779165