0308-041 (CP)LICENSED CONTRACTOR DECLARATION
ff, I hereby affirm under penalty of periury that I am lirensPd under provisinns 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.
q License # Lic. Class Exp. Date
2 C53C ,31/2(
Date Signature of Contractor
D OWNER -BUILDER DECLARATION
D
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 STATE COMPbMATI Policy No. 046-610-:2003
(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 pr •vi ions of Section 3700 of the Labor
Code, I pall forthwith comply with thos pr�visio �f
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, 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 author) representatives of this City to enter upon
the above-mentioned propertt or spection purposes w
Signature (Owner/Agent) ted' _-w�/ .Date
BUILDING PERMIT PERMIT#
fli9�-Qki.
DATE J � VALUATION � � LOT. - TRACT
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le... 1 e`
JOB SITE
ADDRESS ^ nm.w v:1'm3h'wA..9t
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
SHE H0)
CA FORMA POOLS & aPAS CMP MAN' CO
81.266 AVMYP 62 .. -
86.100 ,AVFJ.i11a: 54
LA Q1':I:tNTA CA 92883
COAC'HULA CA 922:36
(760)398.9222 CBL# 00355
USE OF PERMIT
POOL ANTWOR• SPA
COMMI(R NA'L: POOL., PER—APPROVE-0 PL. N;9
1100 . A)<d IVOR SPA 20,000.00 t ,�z
t
1� MIKA VED COST OF IM•olfiS"�Z1�C'3TOJ
PEPI&TFFE RUBIQLARY
PIANI CHICK; FEE %) ISS
CONSTRUCTION MLLE 101-10100 18-000 5.207.00
W—HANIC AL FRE •. POOL 101.000.421.000 31�.Op
ELECTRICAL FEE - POOL: 101-000-420-OUO �Si3.0t!
PlIU itBINO nE :. POOL 101'^000 419.000 00
�.
�•��/,ry�p� �y. pt /,����y..�y T�pap ..y p� �•yY py,�( 7•�+�. �.
6+ �4ioi izf7.t¢St.Jc c.). �i.ivA✓ ]G'1L:�X'i7{V �r 7J�:.WA
p�q+,,...j
$4.3 .55
LESS i.L4.C."FAID i'EZ.i67
$0100
p 0 5 2003
• moi, �:
RECEIPT
DATE.
'BY
DATE FI D
INSPEQTQR
ZP.
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
OX 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
kp
Underground Plbg. Test Z/
.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)
4 V
County of Riverside - Health Services Agency
Department of Environmental. Health
Public Spa Specification Sheet
Owner ame/ ddress (DBA) SAO,v�S' G � .vjd� S (1
City ( L el n j Phone No. 0 Wo — 2ro Iff
Contractor's Name/Ad(ress
City - ' Z Phone No. _ 2 Fax No. ® 2SS
Pool Location/Ad'dress ' '1ria q City
Plot Plan - Shows all existing and proposed facilities including spa enclosure
\
Scale (1/2" = l ft) - Plan and profile drawings Mechanical equipment and plumbing lay -out on plan
_Approved restrooms, showers and drinking fountain if any dwelling units over 300 ft from spa
Spa Capacity 7_15ft Gallons Surface area sq. ft.: Qm��LLtt��
No. of skimmers Make d . Model SP o Z Proper EqualizersAnti-entrapmeht cover '><
Number of return lines/Type of pipe: PVC Sch 40 ,�k— Copper Pipe size at head 3
Pump: Make .zvModel,5V3015F _/40 -Hp jZ Gpm @ 60 ft TDH
Filter Type and Size: D.E. @ 2 gallmin/sq.ft. 110
Sand @ High rate - 15 gal/min/sq.ft. Make tva✓
@ Rapid rate- 3 gal/min/sq. ft. Model' qc, 4Q056
S ration Tank: Make Model Dry well size 7_ft x 2ft Diam ft
Backwash via legal air gap >! Site glass Sewer Dry well I<
Spa onstruction: 'te_ � Other Color: Im
('� -inator: Make 0-1061&) Model p0 -z9
,
fowkMeter: Make . Model 02.!X0 Influent and -effluent pressure gauges
Hand hold around entire perimeter: Bullnose Other_ All co ers coved
Split main drains Anti -entrapment cover All Spa safety signs_ Body hook & ;pole\—
Life ring & rope�� Proper steps Proper ladders, recessed steps, grab rails Proper hand
rails_Depth markers_ Deck drainage Unobstructed non -slip walkways 4 ft wide around 50%
of spa 'peruneter All pools at least 6 ft apart! 'ater supply and fill line from approved source and
approved back flow preventer -><�_' Approved test kit -Underwater light All valves and controls
identified A 5 ft high fence around spa with self-closing, self-latc ' gates,' gates must open
outwards_Openings in fence must not exceed 4" wide and 2" at bottom Contrasting tile for step
and bench_' Spa emergency shutoff stivitch
Additional requirements:
2)