0107-073 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
,Chapter (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
4310 3 t -`Sig CR x-�- 6)7131/22
Pate 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:
( ) 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.
Vi I have and will maintain workers' compensation insurance, as required by
Sectin 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:
Cartier 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
C9de, I shall forthwith comply with those pr 'visions. ".
pate: Applicant`s
Warning: Failure to secure Wdrkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $10 in
addition to the cost of compensation, damages as provided for in Secti 6
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building anraftfor' a permit subject to the conditions and restrictions set forthi
application.
1. Each person upon whose behalf this application is made & each p rson a
whose request and for whose benefit work is performed under or pur uant to
any permit issued as a result of this applicaton agrees to, & shall, in emnify 'r
& hold harmless the City of La Quinta, its officers, agents and emp oye
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„fepresentatives of this City to enter upon
the 'bove-mentioned property for inspection purposes.
Ignature (Owner/Age -° Data
i N., 'S
[+ ,rte
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �y1,(j?j� TRACT
JOB SITE
APN
ADDRESS
7"9 C...°bUX NORM
769-022-07
OWNER
CONTRACTOR/DESIGNER/EN (NEER
xi""INNIAN' T& NMI-GYR.
)RIC51P.AAV (-0QU CONUMUCTION
78-099 CAI.;aXWC►:Et1',Ir'
570 QUAMOtRD
LA Q -U 1A. CA 9.22 , 3
RAUA SPRINGS CA 92263
USE OF PERMIT
POM AMYOR VA
POOL IMLY'. AxAR:MS ' AR??,IMS S11A1W1. VE IN A3dyC & AT P 'COY PQ.rt,.5TER.
R18" 4EMON, POOL lyOUIPlNEE2'11' ENC;T,4 SURE':NOT MC;d UDIRt`Di'1d'iPh'9)..'.
T aY,.J'Kt .R'lbY 6lA'VJ�C ELd-JM1 AFyY�Viye Yl• le
MCC OF C'OI.VSTRU'+C'1?,CON
22AX . O
y�I'gysS�17Kih,°CED
���sb'1.L1.N.L A.5 d9A�JaW�f�37GfF#i.N,i!L1LZ,.Y
PLAIN WErCKE . $144.15
CON5"1°R1.i;::IIIN+1 F&E. 101-000-418 11000 4225.00
1
M1 19HANICAL FRE: .,POOL 101-000.421 °'C*(2 $24.00
i:tAY k'T23CALPER--POOL 201-:300-420-000 1445AZO
E'I.+i3:Q1lV0100 M4:4•• POOL 101'-000.419.000 $AQEt
A
JUL 10 2001
CITY OF LA OUINTA �-.t'L3°l`
FINANCE DEPT L&`1 A13zi-41AIDIS0.
$0.00...
TOTAL�' ��CC� Fly-T.S I��l' NOW
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 Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
1
Underground Electric
Underground Pibg. Test
(o�
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
q
O/Zrf�
G
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)
Duna Gardens Homeowners Association
C/o Wayne C. Nystrom
DUNA 78-094 Calle Norte
44, La Quinta, CA 92253
(760) 564-6008
(760) 564-6008 Fax
July 10, 2001
Karen VanHensbergenr
Re: Pool Permit
The Board of Directors at its quarterly meeting June 30, 2001 gave their approval to the plans for a spa and
pool at 78-099 as presented to them, subject to the plans meeting all current city, county and state codes.
Gain M041V
Sincerely,
X2yne C. Nystrom, res.
Duna Gardens HOA