0209-034 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under prowisions of
Chapter 9 (commencing with Section 7000) of Division 3 df the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6561.28 053 ;QFC'' C: 10 „ f1/E9a
Date c Signature of Contractor :4V `A
-_-w•'' f
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:
Cartier STATE COMPS SATI ' Policy'No. 04611AD6101.01
(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 ection 3700 of thezLabor
Code,PII h f rthwith comply with those provisions,. Applicant'r
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 f r insppeytion purposes. t s
t`if
I "�f ! "! /
Signature (Owner/Agent). Date
�
N
BUILDING PERMIT PERMIT#
r �-
DATE 14LUATION LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
i.01M3 1.00X IAVBLt71'+Ie9L NT CrOMIJf• 14Y
CALDT)XW1A P00 9 &.RAZ (MP Y" CC):
51.40 AV'M1DAM4CIPTM
€E5.100AMUE 54
C RLIM D CJS 92MM
C:'0ACHF2.1.A CA 92236
(760)398.922.2 'c -SU, 00.355
1
USE OF PERMIT
POOL A1+TD101C SPA
P001APA. A1,ARKV8ARPJ +X'.?1ZS :'HALL BE 1W PLACE, AT F►�lP«1'y.,��7'i�.%
INSP.0,01 19, 15 LA 4' 0WCK: WAIA, CITY 0TANDAR%
i
4 Irt. WALL 1100 flit
POOL Ai WOR SPA fi;i6am 9's
NLA14 CHECK FM
CONSTPRICTION FEE 101-000-418-000
A•4TiC.HANICALWE•-T COOL 191-000.4,21-000 524.00
=C ;ICTAL FEE—POOL 103-000-420-000
PLUMBING FEE • PC)fv�L 101 -WO-419-000
„
,•,try � 7 �tdt(
CITY ofLl1QIP WOrA liVL�L31L'.4��JldVdYF�CVI���4r.Kt<i�eiCL!SJ:'+
FINANCED 1.933 PI3:1NP :FHrx8
$0.00 +,
TO'.TA_L J'342Mr MS DUE NOVI'
RECEIPT i
DATE_
1.. �.,
BY
DA ALE
INSPECTOR
r
_.
�P. '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I 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 8 Controls
Party Wall insulation
Condensate Lines
Party Wail 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 i
Rough Wiring !
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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17
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4-4 -CYj'STtt*-`-1 Fk,
7) IINT -rc - A -K
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NA"' FORTENBERRY RESIDENCE --
STREET 57-5q5 5;e,"woLg
JOB ADDRESS j7A-.sA0Eg -
CITY
PHONE OFFICE RES
JI-A ajjrA
LOT '+3 TRACT PACE BOOK
MAF BOOK PAGE ' NO. CITY
MAIL ADDRESS
CONSTRUCTIDN OFFICE PHONE NO,
5FECIFICATION5
DATE
DRAWN BY
SOLD BY
ryn -32 Ir
2
N
SIZE
SURFACE AREA OF
PERIMETER
VEI`Tk* MIN. 3, MA.
<
SPA SPECIFICATIONS
TILE
co
SIZE' 7�- 4, "' go.
u
-YL
SPA DAM AACL VqDTH
TILE TYPE
'roj
NO.
WATER LINE
OF ,IET5
nLETRIm
Lkwr-
GUARTER ROUND
RAIRMi'SPA AT J b?
RB,5. Tltf
IL
5mu.mAy TYPE S7;t 6 STD
SP
SPECAAL NOTM
DECKIN&
EXCAVATION 5TEEL
50. FT
TYPE
FIINSH
p[ J
Ac4m FROM
EXPANUM jo"
ELEVATION
CANTILEVER
DEEP Mo RAmw
PECK VRA#e
L4%1! BEAT
DECZ0 DRAIN
r,
CONCRETE REMOVAL LOAM
CV" GORE
4
WD REMOVAL LOADS1
STEPS
TRW REMOVAL BY
STV- FACE
IRRI6ATIO% REWWAL�
TILE Mam
*"I6ArVN REPAIR
&4v my
a' RDA
RIBDONS
rr Ie Ba.
MM ST"
24' ",5 ft
TAX S1%ftFvEPr0__
MOCK FtWA
MASONRY
Wrims TYPE
"D. FACIIk*
SPILLWAY TY �-E
PLLrr-15IN6
size
STEM
FILTER - SIZE
PROP. EXT. WALLS
POOL Mw - size
P-Ah"rER MALL
00057" RL*.P - SIZE
$MrAWN& VO"S
ADOI. PUMPSL=
r4ALLS
ADOL to"- SIZE.
WATER SIZE
TRE QXCK
" PANE.
ADOL 0AjEZL
W-Twvt Ty"
FILL LIRE
PEBBLE/PLASTER
*AS UNE - STLft
u6ws POOL
LIGHTS SPA
ROLLED BOND eEAM
BeMV SPA
LI&M IN POOL_ IN SPA
STLe WT Ewft�ew
FENDING
KAMINS SIZE
FENCE rr"
GUN ITE
GATE
GATE RrvrtML
c)
C�l
vmr mv RAW
REr10VE 4 MAN*
EXTOVED 2-4 STEP
LOVEWAT
SPILLWAY
LIST. START
C-ARrLEVER
EST. COMPLETION
Wpima
T 4E
OTHER
R.
"is- am STEEL
OMER
O"eR TLA 0) OETER"M THE APoROXIMATe ELEVATION OF POOL OR SPA AT LAY= ON PAY OF EXCAVATION
(2) TAJO NOTICE THAT POOL AND EOUiFI`VW LOCATIONS Me SA9,=T
TO ACCEPTANCE OF
LOCAL OJILP"'16 00*!ARTME AT TIME ON IWAWX OF PERMIT
(5) rer pal" C424cpm SMELL. AT LEAST r,* -,E pA4Ly FOR SEVEN
DAYS AFTER S4!" 15 h45TAWLEV
(4) THATC`ALIiFO"IA FOOLS IS W Ft"p"BLE FOR I)CE�10 C40HCMVMS OR 05JECTS,
AND
10 ARY PAMA&E To a4MS SIDE UL" Mr,1!AAY5 LIOM OR orM ITEMS , Tte A4CEyy AREA
151 "AM THAT ALL FI54N6'6ATES'AM &ARAae DOM MEET LOCAL
COM FOR A FOOL ENCLOSURE
mt'OR To PNV%AdTm NY-wTlm
C�)
(6) FILL POOL ""IEDIATELY MIT" PLASTM (FOLLOW ft'ISTRIXTIONS
- 00 NOT USE MMM mOwj
M TAKE NOTICE THAT rr" ORMNS is TIoe SOLE, PROPERTY 01. CIA�
POOLS #40 THAT ANY
OWITHOUT WRITTEN PM41t&ON OF 6ALIPORRIA POOLS,
M. IS rRO,407W By LAW.
O*IER APPROVES PLAN POOL, AND ZWPMENT L<XAroL'*a APO NAS READ DC RE51"OliI51511-MES
NO NOTICES AeOyE
DATE
SWIMMING POOL PLAN FOR.
NA"' FORTENBERRY RESIDENCE --
STREET 57-5q5 5;e,"woLg
JOB ADDRESS j7A-.sA0Eg -
CITY
PHONE OFFICE RES
JI-A ajjrA
LOT '+3 TRACT PACE BOOK
MAF BOOK PAGE ' NO. CITY
MAIL ADDRESS
CONSTRUCTIDN OFFICE PHONE NO,
II REVISIONS n A TP'
2-
3
4 -
SELECTIONS
CONSTRUCTION AUTHORIZATION STONE
SALES FIELD TILE -C1TX-0E-L-&QU4NTA—
DIG BOULDERS BUILDING & SAFETY DEPT.
PRE-GUNITE. DECK COLOR APPROVED
--FOR-CONST-RUGTIO
UNDERGROUND JANDY
MASONARY PEBB./PLAS DATE -0 By
- -----------
DECK SIGNATURE
PRE -PEBBLE DRAINAGE NOTE: Drainage and irrigation for planters and pots, by
urut:,bb umerwise notea.
t
I
SCALE
DATE
DRAWN BY
SOLD BY
CHECKED CKED By
BY
II REVISIONS n A TP'
2-
3
4 -
SELECTIONS
CONSTRUCTION AUTHORIZATION STONE
SALES FIELD TILE -C1TX-0E-L-&QU4NTA—
DIG BOULDERS BUILDING & SAFETY DEPT.
PRE-GUNITE. DECK COLOR APPROVED
--FOR-CONST-RUGTIO
UNDERGROUND JANDY
MASONARY PEBB./PLAS DATE -0 By
- -----------
DECK SIGNATURE
PRE -PEBBLE DRAINAGE NOTE: Drainage and irrigation for planters and pots, by
urut:,bb umerwise notea.
t
I