9704-053 (RPL)CP
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LICENSED CONTRACTOR DECLARATION
J 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
574127 A / 8/31/97
/Date �� <<% ��� Signature of Contractors
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.
(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
ode, I shall forthwith comply with those provisions..
Date: ` /C�f. Applicant /• 4
Warning: Failure to secure Workers' Compensati6n coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void. if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property:for inspection purposes.
Vignature (Owner/Agent) ��% / �a'ii�lt Date�I�fl��_
i
BUILDING PERMIT PERMIT# CONTROL#
4974DATE
4/110197 VALUATION � g�()1 ,(� LOT- . TRACT
JOB ADDRESS 52-WAVia1�iIDA VA+ LMSM
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
J0191%, SROUKA III
STEVE DODSON ('11ONS f'R.UCTION
52-4505 AVENIDA VELA.SCO
73.011 DOUN`I kY CLUA DRIVES T E. F4
LA QUIN`1'A. CA 'X423i
PALM DESERT CSA 92260
(76,0)3.16-4037 CLAIA 1014
USE OF PERMIT
f:'i•iR.tl.
. (kJOI, ANON ,-,PA t.:fAY
VALUATION 15,0071.1.00 I,S
E31 MAIRD C C),' "T 0117 CMISiTi$UC TION
t 511.00
PCIP(W!' VS+;C;t7i11p,/Iii ARV
PLAN (_`FfV.X FEE 18 81030
c c�t� �i F:tr•I�lt�ta 114.1? 301-")41.;{-040 S16ie111)
A44t'11t4f ICA1.1,1-l' - 1 }071.. 10.1•000-121-0W $24'(00
t.Jkl IRIC At. i�t~;:is -000-420-M) S1S.lfv
1111,JYM-13IN0 1�'HI; •-KWIL 1011,100419{0? $27 ltl1
TOTAL CONS)'1L1JC:'1 ON AND PLAN C'HVC K
$363 30
PAM LESS PI�I, PAID IT
$0.00
APR 141997- rcffAt, PF1d14'!IT IM&S OfJC NOW
$363-H)
CITY OF Uk IQUINTA
RECEIPT
DATE #
BY'
DATE FINALED
INSPECTOR
fl
6
'I � 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
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
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)
PL
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1 1 .
BACKHO
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E; PL
+61
� I �
10,611
30 I —
121.611.
CONTRACTOR cannot assume responsibility for GENERAL SPECIFICATIONS
damage to curbs, sidewalks, driveways, cement
slabs, sewers, lawns.trees, fences. retaining SIZE 14 X 30
walls, sprinklers, telephone lines or shrubs. AREA 376 PERIMETER 83
Whenaccess is made through a neighbor's DEPTH ".
property it is understood that you, the owner. TILE CHOICE T:B.S. S. • 65 -
have that neighbor's permission and assume full RBB +6"
responsibility. COPING CANT .
air life
X
spa 7x7 +6"
3,._0
PL
- \ 21-4
4'-2
2typ
.12'
PUMP CAPACITY 100GPM
MOTOR HP. STA RITE - HP 1
MOTOR HP HP
FILTER STA RITE 300 SQ FT
FILTER RATE 1 n3 GPM
2.
n� �nY LIIYLJ 11 "
SKIMMER MODEL. AM
CHECK vALvE YES.
GASLINE BY s..d.c. FT.
POOL LIGHT 400 CLOCK
ELECTRICAL BY. S.D.C. FT.
AUTO CLEANER NO
CHEM. FEEDER NO -.
EXISTING DECK BY 5•U.C;. SQ. 2UU
DECK 11' 8'�' / STEP FT.
SPA SPECS.
j hOX SIZE 7' RAISED +6"
e ■ LITE 1 WATTS 100 _
light switch / 250 RI LEVEL SEATS 22" 24" 27"
DAMWALL X FT.
U DESIGNER DAMWALL TOP TILE
SEGURA RESIDENCE " "
PROPAIN HEATER SPILLWAY SIZE X WIDE
n jamie SPILLWAY X OPEN CLOSED
i 3 tile seats DATE # JETS 4 UPER LOWER
-14-96
--. x:- ' .. .w ..w.._:.,•.. Name: mr mrs segura
k
,4��� Y OF LA u"U' IN @ A Address: 52-505 velasco
i- city: la quinta
BUILDING & SAFETY DEPARTMENT TRACT cove LOT#
CONOMONALLY
ACCEPTED FOR-,CQNSTRUCTOON
SUBJECT M INSTALLATION AS PER AgS011
POP/S
AND ALL APPIXADLE CODES PALM DESERT
,TEMECULA
DATE - BY 73-011 COUNTRY 28910 RANCHO
Scale: 1/8 CLUB DR.'STE F-4 CALIFORNIA RD.-
' . PALM. DESERT CA. STE 206
NOTE: LANDSCAPE AND FURNITURE 92260 92590TEMECCA.
ARE SHOWN FOR ILLUSTRATION (619) 346-4032 92590 '
ONLY AND ARE NOT INCLUDED. (909)676-SWIM
LIC # A-574127
0