0309-187 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm 'under penalty of perjury that I am licensed under provisions of
Chapt,,*,r;9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect: t .
License # ` �' Lic. Class i l E p. Date
.'Date + Signature of Co tractor
OWNER -BUILDER DECLARAT ON•..1 �.
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.
1 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 Policy No.
:."?'A `f K FUN'D t:ytr42.00J 9334
(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.NoMecome subject to the
workers' compensation laws of Califorr'Ia,.-ah'd agree\that if I should become
subject to tAtl r�
bi
e=wotrkers' compensatiofi'provision�s of Seti��n 3700 of the Labor
Codeall fort4vith coDIV with those o"roviA'hs.
Date: 4 3 91 \ - %1. App1
Warning: Failure to secure Workers' Compensation -coverage is unlawful and
shall subject an employer to criminal penalties an.d%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 I
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& 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-daystkjll subject permit to cancellation.
I certify that I have read this applicafionand
correct. I agree to comply:With;aff1City, and
construction, and hereby authorize represe
th.p above-mentioned property for inspection
Signature (Owner/Agent)
the above information is
relating to the building
this City to enterupon
Date �� •�, �``
BUILDING PERMIT PERMIT#._
DATE 1 , VALUATION LOT �6�y7 TRACT a
,'G
JOB SITE
APN
ADDRESS
' lQ-k-J 72.CAAT?e41
OWNER
CONTRACTOR / DESIGNER / EN (NEER
F
tp3nntGi'3\�tACYY�c�!
k��p.il A�{Miy1sp�lo�"t[3fi4xi�Vf�'�t�'.F13�:3PT.JCti:?l
,
F 9-3 �� �°F�'+h,/1�.k1Y, n)ti!1`7AJ]3A
312.yL�-yy�L�.�{1�'�}l��c:1�.71..:L'[�e'f�.y%Jy'/7�JSd. X
72.
pp jly.
.%ai9 !.Tfl�f irc A.'T225.1'�
C.A. 9225.1'1
(;';
� M1 �{
91v_156
S.rV'VSA.%pi7:.1'�1'fv'�`l.f°4Vi.�.4�.X (.N A, 91 v_156
USE OF PERMIT
PMAPA, PA, ALARi1itMARRIFUUT SMAL-1, BERN' P AC? AT
3.401PEf, TIOX . EQUTPhI:>?A T M:S,iQSl; RF, NOT INC):,UDIED
POOL ANDIOR 3PA f SyA1I0, Q4 i, i
- A` bi3..LLYd.�A.Jv.'�.` > t�;;f,; 9111'OF Q:,43N1"+iJCT; UCII'J;1?�I�t4
�c
PKIM
!'"N CHI= F'1a'l.: � -0Gil�4��'ti�l� 101,30 .
CONSTRUCTION FIZZ a 01-0W-4 I f -GOU 5i 52.V0
MECHAMC.ALFF-L- -- POOL 101-000-421-000 WA.,f10
FRX,,CTPJC A.L. FXE -r P00L 101-000;420-000 1 ti.•Qi'
lIWMt1YHG PEP.... POOL, 101 ^^90.419.009
p' •f.._ � •�}L.'�.�i'r�'1'�Cf.?� .� F��,Ai�� �1 ��. �°��.
� �'�3. x�:�
ik
OCT. 14 .2003
.1..
Of LA OUiAITA.
CIT!'
FIIdAWCE DEPT.
RECEIPT"
DATE
BY e""
DAT NAL
INS ECTOR
4
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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
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:
r VACATION •POOLS & SPAS
" r In LSI r --� ' 9522 Donaldson Road
h�5 tock" - �� ,1jcv5
r Lucerne Valley, CA 92356
jo L� N �!. tJ • �, • N L 13 N i �@ Z ; �D (760) 248-6045
$5 _ .. >T . --. 4 - �' l eU D w� p` . �� n (760) 248-2919 FAX ;
�•t JS-� kms°" ► L iu 4
- �' . N" I � LlU 1 ' �� S � � Lic. #C-53-351673 ,
` w I u 9t
' Sales Locations
Bermuda Dunes, Irvine,
VI
p"1 R California City, Rialto,
Lucerne.Valley.
7 1 800,999-'1811.
GENE .. � �� �� � 3� •� `'� `-}-,. - • ' P C KATION
SIZE
r� x '
AREA P RIMETER
DEPTH - .
Ci �� 00'� ♦ M TILE CHOICE A 7- (pO SQ.,
RBB.
.�` COPING
POOL CAPACITY GALS
PUMP CAPACITY GPM
��.E u ✓ S r MOTOR HP HP
MOTOR HP HP ,
FILTER- - SQ FT
y _ FILTER RATE GPM
HEATER4noAnOSIZE, BTU
TURNOV R' - HRS
.y•' _ �ti.l �• .. - • SUCTION LINES -
-ro S+a Cpti C:. _ 1, `"`.� GGa �. RETURN LINES- ;
�.: �� .. SKIMMER MODEL
i �4, <, :,' C� 1, isa �. . CHECK VALVE
- L 'GASLINE BY F.T.
`POOL LI CLOCK
l.� . ELECTRICAL BY LIPFT. ,�.COa
- - AUTO CLEANER
_.
CHEM: FEEDER .
Y PLASTER COLOR e/b
- DECK BY SQ.
-
" DECK TY
e.
PA SPECS. ,
4 3 SIZE RAISED
' > LITE WATTS
DUAL LEVEL SEATS-
r DAMWALL P
- - DAMWALL TOP
SPILLWAY SIZE, - X WIDE
d0 DATE SPILLWAY - ALL-"--
CONTRACTOR cannot assume responsibility for #JETS.
' damage to cubs, sidewalks, driveways; cement
.. _ . -- _.. ,__�- :slabs, sewers, lawns,.trees,.fences ; retaining,wall' _
NO11�fIb1SN�J v T _ sprinklers, telephone lines or shrubs:
Qn� V ,Name: j� ?- �%Yt
Udd When access is made through a neighbor's property
JI,.13�dS'8 )Niaiim it is understood that you, the owner, have that Address:
C 1 neighbor's permission and assume full responsibility.
dcsu
J111J
a F f DATE s.lq 0 TRACT LOT#
`
tTGNAT&It
Ilk k a . • -