9611-036 (BLDG)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
` t
-/ Signature of Contrractor �
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
Stction 3700 of the Labor Code, for the performance of the work for which this
permit is ;issued- yi'twprkers' compensation insurance carrier.,4tpolicyino. 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 p.rev si ons of Section -3700 of the Labor
Code, II shall forthwith comply with those provisions.
Date: � Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, .in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quintal its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizVepresentatives of this City to enter upon
the above-mentioned property forinspection purposes.
Signature (Owner/Agent)%'"gi-Date i
BUILDING PERMIT PERM T# °°NTR°`#
_
��,11,>36
4 310JOB
DATE tilt3 , -VALUATION �17n _),3 LOT. TRACyT$a
SITE
ADDRESS 54.372 .80U FERN IULLS
APN 769-80"32
OWNER
CONTRACTOR/DESIGNER/ENGINEER
I.':VN'('%ii C'AIs72A703s1Fj:1i
RANCH(-)(APS`.AhO DL1V(fAJV
19l58 (:0LMTRtC7UBAOR #201
796$4C44RWY CU 16 Yw 1,201
I*'kh400AAAJ NF,1 (A 132201
BERM Calif E& (`A 02201
1469
USE OF PERMIT
POOL £1LM_i, APNd '14,94',00-034. 'CR.r .CT 28149. WVD, A24 SF
ltfili.`1 tr.Dt*SEti1kC(I�. tre.�Vv 31�kt105N'
.�s S.IJltj 6 Pa) roP S..aJwnwlc.i. iaN
1. ,5,93.20
PIAN C"klird" IC, ra, 101 O(H)A39-31S.
WL .. 1011.000-118-000.
3::1..i71,UK'Ai. 141.3 to1 $ilk -1320.000
t'I i t��t t�(i Hi�4« ,i fN-t)tn�J l c1..4Hlti :�'l� END
v'i"i )NO N1f(yrWA141114 t - € 21,41) : 101 0001 241. •000
rn
Iltl+1.,4i!`l,rr/ '.`f�P!'1ls Zi�i_iM0_ls j �$?)ucr,
00
d �
81.113 'fMA L 4'.0NS.fll !(A ON :AILD PLAN (.'t tE(: K
Ll:; -';S , itIAYAID FEE'S
TE?`i'r L P14MITFEEN 011ENOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck17
Exhaust Fans
0
O.K to Wrap
F.A.U.
Framing -7
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
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)
Certificate. of Occupancy
Citv of La QU'inta
Building and Safety Department
This Certificate issued pursuant to the requirements. of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 54-372 SOUTHERN HILLS
Use Classification: POOL BUILDING Bldg. Permit No.: 9611-036
Occupancy Group: B Type of Construction: VN Land Use Zone: R-3
Owner of Building: RANCHO CAPISTRANO Address: 79-687 COUNTRY CLUB DR #201
DEVELOPMENT
City: BERMUDA DUNES, CA., 92201
By: DANIEL P. CRAWFORD JR.
Date: 2/19/97
Building Official
A CONSPICUOUS PLACE