0303-167 (RPL)LICENSED CONTRACTOR DECLARATION
I 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
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:
( ) 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 ee 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
Code, I 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, 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 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 forFinspection purposes.
aSignature (Owner/Agent)' �"';' • =`'' - Date
? PERMIT#
BUILDINGRMIT
Pf
.67
DSiTE'' _ VALUATION ' ., LOT TRACT
d2n
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
iiI N_*M9.MUM
-Bi31ka�i1�
2710 CAM90 PstAOL1d
WACIY6. T C-R . S1414
USE OF PERMIT
POOL AND/OR SPA,
P0OtlwPA,W.ailNC FOR, FUTURE .55Q.ALA8uA3i~RS SHAf.BE
yPitA'CEAT (t&MAY£R SPTy3ION. aQUrPrCdCpkl.0DURF. A110
I•d�CLIJi?b�d;�
POOL R1vd:?)OR SPA 211,000,00 LS
ESITO"M Cour OF COMMUM101y
2%wo,00
PEWE'r FEE Ste Ma
PIAN CHECK 79F, 101-0 0-439-318 01XS3
CONSTRUCTIOW VES 101w000-41&000 $207,00
MTf.[✓HAWXCA.,FEE ---POOL 101-000.421-000 $24.00
XLECTPUCA;C., FEE 11rOC9,L 101,000-120-000 $45.00
PLtiMRCNlG1?ff_9 P00L 101-000-419.000
�J
MAR 2 0 2003
MAR
OF LA QUI E!A
CITY
FINAmCE DEPT -
BUIL -TOTAT_ C<)�'�," MITMON AND I)LAN CMCK
$437. S a
IMS PWX4 &4
$0.00
WEAL MOUT FM E NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
— 11
-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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Finaa
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)
i
2710 Camino Diablo
Walnut Creek, CA 94596
925-934-7926
�- 1495 S. Winchester Ave.
San Jose, CA 95128
Quality Pools Since 1954 408-866-6893
1804 Soscol Ave. #102
State License no. 574198/C-53 Napa, CA 94559
707.--.648-7926
CONSTRUCTION
SPECIFICATIONS
- EXCAVATION:
1)
POOL SIZF� -L� �'X _.�.r.—'
9) SPA DEPTH. _� ��^ "
2)
DEPTH TO TO _
�_'
�
10) POOL CAPACITY �lU GALS
�f) Y''
3)
AREA sQ. FT. PER
11) FILTER RATE GPM
4)
5)
GRADING HRS
TRASH LOADS __ __-_-___
12) DIRTWALK __E20 FT.
13) FENCE REPLACE BY 1_-
6)
COVER BOX
MISC:
7)
TRACTOR ACCE S._w. / FT.
Z�-___.X
MISC:________
8)
SPA SIZE _� er �_ __.__'
MISC
STRUCTURAL:
1)
RAMP
10) DAM WALL �6_Z: 'OF �� f� _
2)
SWIMOUT__ __-_-___.-_____.___...._.__FT.
11) TYPE
3)
SWIMOUT _-__ _ FT.
'v /
12) ROPE RINGS
4)
RBB: ,/ FT. OF ___
13) COVER BOX
5)
RBB:__27 FT. OF
14) SPA SPILLWAY SIZE
6)
RBB: - FT. OF _.__..v _—_"
MISC _.------------.__..._
7)
RBB: _______FT, OF _ __.__"
MISC
8)
RAISED SPA
MISC . -- ---------
9)
NOTCH SIZE
MISC:NO
REBOUND
IN PLANTERS
PLUMBING:
STUB PLUMB:OYESONO
POOL:
1) RETURNS #_.W/AIM FLOWS
1-4
1) JETS # __r __.___. W/AIM FLOWS
2)
SKIMMER #.---:/ ____._.-_-� __.�
2) SUCTION __�it5__ _ .__FT. OF
3)
SUCTION _ FT. OF-_ "
3) RETURN z FT. OF "
4)
RETURNS OF-.e,�_y _'
4) AIR LINE_ FT. OF
"
5)
RETURNS _/,_---__FT. OF _ _ ! -"
5) FLOOR__-_ _ :"�' FT. OF
6)
CLEANER ___3_' __- _..FT. OF z�iZ-_'_'
6) BOOSTER __ t t? _FT: OF __
7)
FILL LINE Jam_____ :..FT. OF .___°
7) AIR SWITCH c'_q__FT. OF ( 1" )
8)
AUX. PUMP ----.FT. OF .._ __. °
8) SUPER SWITCH �/e_5FT. OF ( 1" }
9)
WATERFALL ------.-.FT. OF _---___-'
MISC_--
10)
COVER DRAIN--:__---_. FT. OF ( 3" )
MISC:-._...___.._.._:::_...._.-_._-__--_____�
11)
T. P. U. YES ❑ NO
MISC
MISC: _---.------- _____.___ _:
MISC
IF YOU HAVE QUESTIONS CALL SWAN
GAS
LINE:
GAS BY: __� ''> " — ... �...:. ---
MISC: (__pet, _(;,?,:A 15
1)
HOOK UP BY:.__ 2AMA C_ _
MISC
2)
GAS LINE _._1 `l _-_. FT. OF S?---.'
MISC. --; .----- _—._---------
ELECTRICAL:
ELECTRICAL
5) SUPERSWITCH FT.
1)
ELECTRICAL LINE 1FT.
6) COMPUTER LOCATION
2)
LIGHT SWITCH LOCATION
MISC
3)
_._.
POOL LIGHT FT.
MISC: -._-------_�—._.
4)
SPA LIGHT _ �Z�----._.^__.
FT.
MISC: __.----_----- ----
M ASON R Y:
1)
WATER LINE TILE # -�- � -
-r t
8) PLASTER COLOR=.(
2)
COPING-�� _- T �i _
9) DIVIDERS___ --
3)
TILE TRIM --FT. OF
10) SPA SPILL. BRIDGE _._-___OPEN
4)
5)
FACE RBB WITH _
CAP P..3B WITH
MISC
MISC —
) ..
FACE c;.-A__WITH
7)
GROUT COLOR ___.d'.-.--_-...
MISC.
DECKING:
DECK BY
1) TYPE
7) DIVIDERS ._✓�j�'"{�s t
2)
MESH
8) EQUIP PAD
3)
MASTIC
MISC.
4)
STEPS /v' ....: __ _...:_.. _.: FT.
MISC:
5)
DECK DRAINS .. _.._ �.. __-- FT:
MISC
6)
FRENCH DRAINS _ _ . ___ .___ _ FT.
MISC.
NO CONCRETE
IN PLANTERS
EQUIPMENT:
1)
PUMP H. P.
,
8) SPA LIGHT
2)
FILTER SQ. FT.
9) SLIDE _.. �_.__ -----------_..---
3)
HEATER BTU
10) DIVING BOARD -
4)
CLEANER.-__....
11) COVER
5)
BLOWER H.P.
MISC:
6)
BOOSTER_
MISC:
7)
. POOL LIGHT _/>
MISC:
--p OW ER:
NAM6:_Ta I-L�7 CQ`_Tlri-i`� .�___ __� N/u es _
ADDR
P
CITY:__
_ ____..f�__C.� 11v '�J9__._ _.a
ZIP: ---
__LOT:
LOT:_-�-----------_---_�____
TRACT:
CROSS STREET:
RES. PHONE:
WK. PHONE.—
NOTICE TO OWNER:
*
OWNER TO DETERMINE ELEVATION OF
POOL ON DAY OF EXCAVATION.
*
OWNER TO FENCE POOL PER COUNTY
OR CITY ORDINANCE. GATES TO BE
SELF-CLOSING AND LATCHING. DOOR
ALARMS MAY BE REQUIRED.
*
OWNER TO WATER CURE GUNITE 3 TIMES DAILY FOR 7 DAYS.
*
DO NOT WALK NEAR POOL EDGE, INJURY MAY RESULT. SCALE: 1/6"=1'-O"
2710 Camino Diablo
Walnut Creek, CA 94596
925-934-7926
�- 1495 S. Winchester Ave.
San Jose, CA 95128
Quality Pools Since 1954 408-866-6893
1804 Soscol Ave. #102
State License no. 574198/C-53 Napa, CA 94559
707.--.648-7926
' 1E.
CV •�
tis • \ '
of T1� : ` 78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253 °; 3 • -
TELEPHONE (760) 777-7012, FAX (760) 777-7011 r ,
.
OWNER/ BUILDER INFORMATION ` ' Y '
Dear Property Owner:
An application for a buildingpermit has been submitted in your name listing yourself as the builder of the property
improvement's specified.
For your protection you should be aware that as "Owner/Builder" you are the responsible party of record on such a.
permit. Building permits are not required to be signed by property owners unless they are personally perfoiming their
own work. If your work is being performed by someone'other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name. ?
Contractors are required by law to be licensed and bonded by, the State of California and to have a business license
from the City or County. They, are also required by law'to put their license number on all,permits for which they -
'apply
If you plan to do your own woik, with the exception of various trades that you plan to subcontract, you should be.
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than.your immediate family' and the work (including materials, ..
and other costs) is`$200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an emploq er:
If you are an employer, you must register with the State and Federal Government as.an employerand you are subject
to several obligations including State and Federal "income' tax withholding, federal social security taxes, worker's"
compensation insurance; disability insurance costs and unemployment compensation'contribtsiions-`'"
There may. be financial risks for'you if you do not carry out.these obligations, and these risks are especially serious with
respect to worker's compensation insurance. -
For more specific information aboCii your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stare
Law, contact the Department of Benefii Payments and the Division of Industrial Accidents. ;
If the structure is intended forsale; property owners who are riot licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or, subcontractor, only under limited
conditions. { `
A frequent practice of unlicensed persons professing to be contractors is to secure an 'Owner /Builder" -building ♦ '
permit, erroneously -implying that the property owner is providing his or, her own' labor and material personally.
Building permits are not required to be signed by property owners unless they are performing 'their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street@, Sacramento, California 95814.
Please_ complete and return the enclosed'owner-builder verifrcation`form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned:
Vcry truly yours,
J '
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Cale Tampico,
La Q nta,, 92253 i
(760) 7 012
FAX (Z�0) 777-7011' . - ♦'„ -
' OWNER'S GNATURE/DATE
ADDRESS
PROPERTY
7-
PERMIT NUMBER(s) " '
t
t
. •i' -
. • - .-f. r '.�
,,�-, �.
13/12./03
Vernon
Vermes, authorize
_John Lawrence to pull
permits`
for a swimming pool` located
at PGA West -Lo't' #9.
The
address is-81-225,'Tiburon
Drive La Quinta, CA.0/1
i
010/1
ZI-ISO,
• • '
F r
-
- •I "
_
JOB ADDRESS- ams /�LC,C6Y�
L:1 1 Y OF LA QUINTA SUB-CONTR TOR 1,LI��T
PERMIT V_19:
.
This form shall be Hosted on the yob with th_- a f3up)diy Inspection
NUMBER 0. 013 -Z& 7 OWNER %IVES BUILDER 0"'�.Li7i� — Ylli//l DlCD
Card at all times in
a conspicuous place. Only
on this job. Any changes to this list must be a y persons appearing on this list or their employees
approved by the Building Division prior to commencement
are authorized to work
of work. Failure to comply will result in a stoppage of
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable
work and/or the voidance
de / Classification ' Cormactor
-response.
Stats Contractor's Llcerise_ ' Workers Compensatidri 7nsuranbe
co
CM
Company Name
Classification
License Number
Exp. Date Carrier Name
City Business License .
m
FFRAMING
(e.g. A, 8, C-8)
(xxxxxx)
(xx/xx/xxl (e.g. State Fund, Ca1Com Form Number Exp. Date
PI (Format Varies) Ixx/xxlxx)
License Number Exp. Date
(xxxx)
HWORK IC -121 G
gQZ-IO%
I�!/
(xx/xx/xx)
N
RETE ) •
D S tom/ R.o/ v� ILis I o
vy g33 /t•a
p•
(C 5) :
588 3
i C s iC % �5^O. G3
—_ _
- r%Z I� ��
J
iD
J
STRUCT. STEEL (C-51)
MASONRY (C-29)
PLUMBING (C -36) -
LATH; PL SiTER"(C=35) S
UfiYWALL (C-91 .
HVAC (C-20)
ELECTRlq: L (C-101
ROOFING (C-391...'
SHEET METAL (C-431' .; .
FL-OPRING.(C-15)..' ;.
GLAZING (C-171
SEWAdl DISE},..(Cai2)-.::%
PAINTINq IG-3Sj.:. ' .
ti�e r—
bOL-10:S31`.
Qvwr�hrt 78
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