0108-227 (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,lj cense is in full force and effect.
License # Lic. Class Exp. Date
•X
J,
pat�3 ,Signature of Contractor��,,rrf� �' "Ry"• ""�`-•�'"
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 Policy No.
r,2CEMP171014 SAN F114
(This section need note be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject>to the
workers' compensation laws of California, and agreel6t if I shouiAecome
subjeet,to the workers' compensation provi i ris OK$�ec�tionn 3700'of the Labgr,
Cole, I shall forthwith comply with those provisions./� ~
pate: 4. �.r" ^_) Applicant=:*✓'r%'X?r
e:.. ... f ���„�i'O. .. ,,. yrr/./'f'T ��'..,.4-yrst�`�'•-2„+'`''�'�:,M„'",..-:
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 cf 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,r{elamg to the building
construction, and hereby authorize represen�tives o t@s-G*To enter upon
the above-mentioned property
�+fo rinsp�'ron-peiroses.
Signature (Owner/Agent)" ;e`/ Date,t! r''-:
BUILDING PERMIT PERMIT#
DATE r VALUATION LOT Q�,{t la4` f TRACT
JOB SITE ,
APN
ADDRESS,
&3-7W AWN"A x2MR=
-
OW-NER
CONTRACTOR
7jlkTAk, CMM 7 IS
�y/ENGINEER
py/DESIGNER
� .t�J.J"d.`I.::+�r .,J�v.•,1.ti7y LL"ft.r.
53 m1750.ANT1.XT.r: AJUART..:
?0.18.1T'k'11i.11ITMIAR(M)48
LA Q:mrnp,
L id F10100R G 'r;'A 92270
(760)W31-0860 M-4 3135
USE OF PERMIT
POOL ANDIOe: VA
.POOL OK .% ALA9MV8A'9kV1_ RS SHALL HS IN PLACY AT PRE -PIASTER'
19-SPECT109. PrOOL EQUIPWNT Wt' WSURE 13O'k INCLUMD,
18j300,00 LS
1F� $y1�3.LNfi5.7R �rM.O� LSA �J.GY�� 7r
PLAN CH WK PER 'W],-000-43,9-318
s;:OABbIT;I2.f t'CVON FRE 101-000-419-000 Yti9ffi.O[t
ELECTRICAL FEE -- POOL 101.000.420-000 50100
PLUM31140 YRZ POM 000 11-217. 00
d kTrTS" iL014 AND PI.. G.Ei�?C
s a 7,:103 Prde, PPXDa4US
$0,00
AUG 23 2001
CITY OF A
FINANCE DEPT.
RECEIPT
DATE
BY�f `
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.
Frai•oing
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
Set Backs
Footings
Steel
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
l0
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
tttt
Gas Test
Appliances
Final
(/
_ t
COMMENTS:
Finan
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)
n
1qPOO
SEVADA
MARK TOW.
70180 THUNDER ROAD
RANCHO MIRAGE, CA 92270
PH 831 0860
laC. /1777601 D-4- -rL C k e T. 6- N - C)U
P
k
V
(01
� f• P.
Designed by
KERRY R. KOEHNLEIN
PHONE 360-0012
I<I
A'� -
LSTY
tp
-A RE-IN&I i NPFEE OF $'
WILL BE CHARGED IF THE APPROVE
PLANS AND JOB CARD ARE NOT 0
THE SITE FOR A SCHEDULE
INSPECTION.
NQ EXCEPTIONS!
i+'IS
FOR
2 rt
V
OF LA CQUIN A
'G & SAFETY DEPT.
PROVE[)
ONSTRUCTION
8Y_
OWNER to fence pool area and install self closing and self latching gates per code.
NOTE: No dirt will be removed, returned or graded after day of excavation.
NOTE: Relocation of equipment pad will result in additional cost to owner.
NOTE: FII pool immediately after plaster (follow instntctions). Do not use rubber hose.
NOTE: Do not turn on pool light when pool is empty.
NOTE: Wet down concrete shell at least twice daily for seven days after shell is installed.
I
I have reviewed this plan and hereby approve total plan b specfiptions. -� g t9l w
� A-� Cluj s
DATE CUSTOMER SIGNATURE
POOL SIZE 7 X_L Depth L2;-X1� X
Surface Area ,SC* Perimeter_
EXCAVATION Access Grading
Dig From 5 k;t w..p u+ Obstacles W * 101.. .
Walls Removed _1 -f % Replaced �S
Misc. 0 0
1 to iLf o copjc GTe f
PLUMBING Rfter -C-W4( size-3"O—'O fr
Pump AC-Q,t 1, Sae t k :Booster Pump
kim Runes Main Drain Retj—
ill Line Q -J c o Purifier `J*�-'r
Auto Cleaner Pp 3 It. -C)
Htr Type_ Sae Gas L/F
FOUNTAINS—SPRAY HDS—WATER EFFECTS
Type 00 .Sae
Plumbing Length Valves
Booster Yes/No Type Size—
Misc.—
STEEL
aeMisc._STEEL GUNITE En Sur -charge g
6' RBB "' 1r — 18• 24'=
Step Risers 3 Spa Wall Width—
Benches—
idth_Benches Z- Love Seats
Spa Dam Wall Notch —
Misc.
ELECTRIC Total Run L/F '� ° + FiberOptic �1 D
Remote Spa. _ . ND
Misc. _
TILE wino 'V e S Coping I(&
Step & Bench Tile# Ve 5
Misc.—Glass—Etc.
DECKING Sq Ft 3 � o Typed AE- Color
Nat Concrete Sq Ft Cantilever—j G�
D.O.D. OF Step Risers
Misc.
SPA Sae Area, Per
Pump Biower_ Spillway_
Jets Step Light_
Misc.
INTERIOR FINISH P Lr, b T.4 Color h1le
Other 13 A L -T ,e e- C e sem% 5!1 .S
OWNER Ca -LatLey-,)L5
ADDRESS f3 7 5 y - ZJ A 9 t�
CITYL& Qurl7eS0LD BY� DATE- "I`E -a
PHONE -(H)
DRAWN BY DATE - g'�
-- 1 5 `(