0201-173 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am Ilceftdd under OebVisiong 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 # ayLic. Class Exp. Dafee n
�5 (51111.10: '�l� r In 1103
Date, .. 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).
( ) 1, 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, assprovided 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:
CarrierS•�a.«� i SIL Policy No: M-91-0019XV
(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\becol a subject to the
workers' compensation laws of California, and ag'ree•-that if I should become
subject totthe workers' compensation provisions„of'%ection 3700 of the Labor
Code, I�shall"forthwith comply with those provisions. 1
Date: 1 /9 Applicant—
Warning:
pplicant 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 offlcers, -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-mentioried property f&lnspectionIkurposes. f
Signature (Owner/Agent)h`; Date
BUILDING' PERMIT PERM T#
DATE VALUATION' LOT ()201-173 TRACT.
10
JOB SITE APN
ADDRESS . 47,4045 AqA A1fXW 3
I OWNER I CONTRACTOR / DESIGNER /
CARADAY& Ct3WARY 'RAL L H AI6WrC)N' Ciba V iACRT'Fi. M POOLS
174€ 0 B. 17TH Or. 1A OG 9 5 22 DIDNAU, ASON VD's
I'M Am CA 92780 WCWtVE?VAUJ?,Y 92356
(760),246-6045 CDIX4335
I USE OF PERMIT
MM, AMUR VA
POtis.fSP,ft..ALAWN1HARRIERS SHA.14, RVE t•N PLACE ./ T PP',:1.44-.!!STEIR,
1%6a:1MMO141. E NOL i' L1IP i`�AI1 >�1c'1 tl�r 1(3 i Ce��E':i..CTfl�4�.
VALUATION
} 4000100 I's
15AM
PMR iii' FKR WMI10-TARY
PLAN CHECK FEE 101.0004439.3118
ON$11RUMION ME 1,01-0M.418-.000
MECHANICAL FEE – POOL;' 101-000-421-000– V24,00
a-000Ptr.tr0
PLi1k.41311, o FF.,F1 -• pool, 101-00041,9-000 ' 1427.00
JAN 2 � 200 1 I
"-cm M U �@9MA fl
FR�PM-P.: •.fie ---i
S:3-TtY1 ' . '! 1113 ARyl� Y''��1. �/yl�ty�`r:�i''�'�"��"�;: ��++ jj ,3 [c�i. Cryo
44311, j � FATI1'd;O �:+M1�
RECEIPT DATE BY DATE FINALED INSP R
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
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
1-2,C
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
G�
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
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:
r4
VACATION POOLS & SPAS
9522 Donaldson Road
Luceme Valley, CA 92356
(?60) 248-6045
(760) 248-2919 FAX
Lic. #C-53-351673
Sales Locations
Bermuda Dunes, Irvine,
California City, Rialto,
Lucerne Valley
`�--� 1 800 999-1811
IN s
N
CHECK VALVE
GASLINE BY FT.
POOL LIGHT CLOCK 1
CHEM. FE
PLASTER
DECK BY
DUAL
n
CONTRACTOR cannot assume responsibility for
damage to cubs, sidewalks, driveways, cement #JETS
slabs, sewers, lawns, trees, fences, retaining walis,
Sprinklers, telephone lines or shrubs. Name:
When access is made through a neighbors property
it is understood that you, the owner, have thotAddress: 14716 S V "'9 /+Aj ! ; b�S
neighbors permission and assume full responsibility..
Qkj' L'at
DATE I7 OZ (a ka s e TRACT LLQ. LQT# J �B
SIGNAT E -7