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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penaljy of perjury that I am licensed under provlslons-0.A-.
Chapter 9 (commencing with Section 7000) of Yvision-cif the Business antl tx
Professionals Code, and my License is in full force and effect. ;
License #. Lic. Class t Exp. Dater.' ;f
163 C53C s t R 3Y93
Date t Signature of Contractor.
OWNER -BUILDER DECLARATION' i
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.
,\(f) 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 :TATF t�U)gD Policy No. ?.i9-fPt-Ol�1!13''44
(This section need not be completed if the permit valuation is for $100.00 or less).
() 1 -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 w�)rrkers' compensation provisions` of'Section,3700 of the Labor
Code shall`forthwith comply with those provisions.
Date: -`•,,` 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
the above-mentioned property for inspection purposes. ,
1, {
Signature (Owner/Agent) ; a,.� t Date';, ( 1
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3.
:k - BUILDING PERMIT ` PERMIT#
l)ATr;,_ 0 -VALUATION ' LOT 0;201-174 TRACT
,, ��((yy (�}}��'
k I51000.00 149
JOB SITE r
ADDRESS 1-135 VIA ARMES
APN
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
G`'AM,f1DA7r"' & (!0W)A X
,L sUkYv f0N dba %rAC'AT101M :POOLS
17480 F l7'M WE 40 06
9522 DC7N.PsIZ30M R.D,
CA 92.780
;,11CZ°�M VALLEY CA 92336
(760)Z486045 CBIA 4335
USE OF PERMIT
HOOT, AXTI OR. ISP A,
PCX),%JF,PA. AJ A;?u7Sik3P,} XJRS SHAL), fig IN PLACE A.7 KWePU,STER
N3.Pit'•t:.'T10Ai. POOL tf,Qi3IPltiai'EAi'I` FAi MOS`7 RENO T INCI;UDEa
:L
V.ALUATM D,%CAQ,00 LS
ES117MXMID C;C3ir'11 OF CO3W1YR111 MON
1519W100
MRWETi` IT. SUMMARY
PIAN CHWIK RK 101 -000-09-316 S 10: 30
C011S i k1lJtC: 10H FEE- $151.60
MEICHANIWI, M r, PML 101-000-411-000 $24.00
W,,C PIc3C 14L PEP -- ;P100L D C! : -000-420-00.0 $45.00
JAN 24 ZUOZ 4 'h
WYOFLAQUI A- ,
dt'JR Tti"�1 %.C; Ade ,CiC,°-101, moI)Dk 7 C''i cyc
$363.30
Y �' qy ,�yp� !
z �s07 P.RU-P.4"1AD PEE
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$0.00
TOTAL PFR-M'f 2_0 ME 140W
RECEIPT
DATE
i
BY
DATE F FjLE
N
INSPECTOR
1
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
d
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
t Z J
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
z �2
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
A
Plumbing Top Out
Equipment Enclosure
_
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
�p SSS
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:
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CITY 0
BUILDING & A DEPT,
PROVE®
FOR CONS
DATE - ayL BY
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VACATION POOLS & SPAS
9522 Donaldson Road
Lucerne Valley, CA 92356
(760) 248-6045
(760) 248-2919 FAX
Lie. #C-53-351673
Sales Locations
Bermuda Dunes, Irvine,
California City, Rialto,
Lucerne Valley
1 800 999-1811
CONTRACTOR cannot assume responsibility for
DATE
SPILLWAY#JETS
damage to cubs, sidewalks, driveways, cement
slabs, sewers, lawns, trees, fences, retaining walls,
sprinWers, telephone lines or shrubs_
Name:
When access is made through a neighbor's property
V"9 /4AJ
it is understood that you, the owner, have that
Address:
t17165'
neighbor's permission and assumef II respo Sibility.
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