0212-095 (RPL)LICENSED CONTRACTOR DECLARATION:'''.
I hereby affirm under penalty of perjury that] am licensed under provisions of
Chapter 9 (commencing with Section 70001 of Division,3 of, the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
634611
Date, r jr. r 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 riot 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
() 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:
n
() I have and will maintaia 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
perm i" is -issued. My workers' compensation insurance carrier & policy no. are:.
Carrier.. AT�;1''th1-� Policy No. (34618{2
g(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 orthwith comply with those provisions.
Date`: a Applicant.
/� � y..
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 pursuantto
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 for inspection purposes. .
S' t Owner/A ent) ✓ r�.3�• �: ^"�”61.� Date -oar ..
Igna ure .( g
.,r
PERMIT# '
"�... `JI•LDING'PERMIT '
DATE VALUATION spy LOT TRACT
JOB SITE ADDRESS ...i VAY��NC IA C-01J�27f.'
APN «
OWNER
'CONTRACTOR DESIGNEREN 1NELER�gy
�1 ry�rh �+�� ���e� �'
0EDOM t+'.RV.Sl�yl� ,4iV
,1.YA�.•.i.CV F. d�L`:.T� PC LZ Ai �� IP:/0
-17r s&I coamI}�� ��£..'�k3 m,M. =1�y I. 5v
P.O. BCA 1791....
PAIN, DYKSRR,`t CA, 92211
12kQ13MA CA 92253
-
�"9fiti;3 ��f3����:1 �'1�• 198:1
USE OF PERMIT
PDOUSPA, ,�A ARMSIBAR .:.i�RS SH SHALL BE IN K.ACit:.�' V PK&P�1...ltt.�'rm.
IN`O1�'L�`31014. I?QUIP'siEAT CLOSVIONOT 11dC1=UDEM
POOL ANDIOR SPA 131009.0 111-0
MAN CHECK 1 10� -0004139.316 $104110.
1:f:'+1� STf[1. V 101q' 101000-4?S•-000 Ai62.00�
bb14�'�idi�•i1CAL �''-91. -- POOL 104.000.421.000 $2+4.00
Ni„I CY'k%€�,,�L,1+�.. •-1>OOL 10 1 SOW -420-000 �sS:trt3
PILUMi�WO9 FF -- POOL
DEC 2 0 2002
CITY of LA c UINTA
r - F C _ PT Y' 4`1:x. XITAN1»i?.',4;,PX CN. 51%
�a1 z�ZE-,Pl APSH3
ATO?T :I?;By�.N�IT YNTIN ��• NOW-
• 1.111,.
RECEIPT
DATE
By
DATE FINALED
INSPECTOR ,
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
0. 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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover—
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
_Gas PLUMBING APPROVALS
lect Tet
Electrics
sFinai
'
Waste Lines
Heater Final
kWater 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:
x 6'
'
PEBBLE 6'
.
BOULDERS--
FINISH..
PL
y'
P.L.
-5',6'
SPA +18" IMTH.
V STACKED STONE
PL10
30' 13'
SPILLWAY WATER
UNE. R-BOND
-3.90
BEAM
BE STONE
FINISH.
'PL.
ENTRY, -
STEPS
POOL
D
CANTILEVER
EQIJI
lJ
PL,
COPING
7• o =
o
ZERO
GRADE
P
WASH FINISH
L
;,P'L A.N
.III