9912-167 (RPL)LICENSED CONTRACTOR DECLARATION
:I hareby 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 Contract
OWNER -BUILDER DECLARATION
I hereby affirmunder 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
� ,erfqrpance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
SMI 3700 of the Labor Code, for the performance of the work for which this
perm?, is issued. My workers' compensation insurance carrier .& policy no. are:
Cartier 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 C lifornia, and agree that if I should become
subject t the workers' compensaon provisions of Section 3700 of the Labor
Code; I s all fo hwi comply with �hosg��i'rovision
Date �Applioant t �
Warning: Failure to secure Workers Compensation cov rage is nlawful and
shall subject an employer to criminal penalties and civil fin s uP to 00,000, in
addition to the cost of compensation, damages as provided�fo� 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 • setforth 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 authorize representatives of this City to enter upon
the above-mentioned prop fity for-inspecti n pur oses:
Signature (Owner/Agent) Dat 2
.
BUILDING PERMIT PERMIT#
DATE J� J e I/, r VALUATION q LOT TRACT
jg)
JOB SITE
ADDRESS Si -:99/ LAUM9LVALLE
APN
- -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
}
.C.M14�.1A M�t{4i„e �1i if liY./AI,l.1'i�
a-i�l A.`ANA.�.�JA$4J-M �.�,..
fW -9) 7 a..P1.�J:t.C3.I r VALLEY �r.
110 BOX 1313
LA QUIN'I"A C'A 92253
'!.tAN0140 MI.RAG.P. CA
(11Wo).5J6_fa5)T G i., 5955
USE OF PERMIT
POOL A.RDlE)+e'f, �Pt'
i
POCZ ,ASND TAtl1`at. ► - ,i§i �°11��1p + rpt{ rk lL SGAU1. ids
i'•�:;:I. »:deli<?r�i �:i�l3i, :�Cf.ifC"v.tl: ).. s^
'1XION,
Ya�3lF�vca.
y� 9 �1g ,�, p pY,
ViT
1-11L AN CIMCK FM SO4.55
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SAP NS
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{. yy�,,�.gq, 'y py.}p.�,�y
. 11 Yi' L PERMAT K9�IOS 0115 .' NOW
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RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
y
L _/
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 �9
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
RqqgWWnd Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
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
EncapsulationRO
Gas Piping
Gas Test
Appliances
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures�`p�-dj7/�
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Fina4
Utility. Notice (Perm)
Final 3 /�
COMMENTS:
,/e�yygL �/�/lll i?+ -7 -UPS~
' Field observation for pool final inspection.
3/9/2000 Mr. Adams and the Senior Building Inspector Kirk Kirkland discussed the correction
for the minimum clearance 30" x 36" at the pool sub panel, I issued at pool final 2/28/00. An
understanding was reached by both that moving the sub panel to the edge of the block wall will
be acceptable. Direction was given to me to approve this installation.
Daniel P. Crawford Jr.
Building Inspector II
r
1
L7 4 4 771
LJ4 Lx .4
UUYER/OWN /S
ADDRESS CITY RES. PHONE CONTRACT DATE
t.
MAP GOOK PAGE LEGAL DESCRIPTION LOT
TRACT JOB PHONE
I,,) lu!,poritoblu lot 11in •r
Collilactor Owner
....
by.
ih Fn w,d by
.. . .....
m
hv "001
C)", 1, I'll) by
1. 2,_"1slun -Iints by--
Permits_ by
WAO Vontina by
t J
_10$,, 11) by
i bvn FS
by------ 1.4
I Es I AN
,.,,t1L;T I:JDICATL LOCATION ON THIS
SiA I ALL
I DRAWING OF ITEMS J5 a.
I I I_
, I, EtOW AND THE FOLLOWING
1�05T BE ACKNOWLEDGED BY
0'%WJLh'S INIIIALS. not,
.2.h2L1,2 nl Pool
\.. j .
of Pool
I *nulli- - " . I
AA -:;T -0
arist
Filtof I oc '11-11'L. 4_&3(E1Q_#
I
Im"JI101111,
Col.
V
lZIP
2c, Itioll .41,
i -ii w Loca lion 4.1
EV4Vrl
7'
7
2
1 (IC aT, 1,41: FOl I�OWING ON
17
A
r
in Slopes rn
rn
It "Cl, I t.a,7 Pollit
a,
!=. M = -0 4L =!kta Sir, ki-Viti ! / J` ` ; ,
I'll -00 piltio
ci
M
C
C2
coo :Imp rn
bit tit,my ily I on'! rn n6W_ M
c G
uttt,IV La UA rM
... ... ,it prup
rn C) M CA31
CUSS DAMAGE OR I )NO ERGROUND C2 4=
TIONS:
CONDIAGIOR i-117lot assuma
llsib.hty fn,- d,irn.ige zo Curbs,
III 0WOVS, C01111.101 Sldbs,
3 1•
1 A :' , it. 605 1 tj licit s, re -
It -; . - : I ib a;.rl f'" s. 101tiphuna
It, 0, " ;.I 'I " fjd> linu t, u r shrubs.
.1 ,-sN is made through a
. jj.i_W� piritpariv it is mide,slood
.h..t ;." 0.0 owmur, hdva that neigh-
p.mw,sion and assume full
.(.� Pit' '10VES PIAN AND SPE
— CI -
TI A'
Op4s S 00111-INED HEREIN,
1;�; IIA-; ACCLIVED A COPY OF
flus 1.1 AN
C. () D E
I'l f Il. FILTER HEATER
G I#
G a 's El kc.
t.1 1" 1 F R METER
,,ISE M6 ELEV. Pl.
I ADDER LIGHT
0 broad V Over W.L.
S' Board V Over W.L.
I a
q: 06rd 2: Over W.L.
12 Board 3 Over
W.L.
S i D. FORM NO. T-3309
ca
M In
0 r nz
M> G a
0
0 0 PS&
Z UND
0 Cn
C: <
0 M C
0
z i Pte. rec
Z M
exw,bgm
1. � + r :�.�; � `
Decking shown is for illustration ONLY., LENGTH
Customer understands they are to receive,
ICY-) sq. ft. of deckirig as
per contract. I i Access: I I 31
DEEp SNEND
j.A 0
X L5 ft. ro in. E III uL l4r.?
NOT TO SCINLF
i
I
r -v
Olt'.
,,, ?,�, �.
fz.3 KV L; Z2
ZE
cc
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ji
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BUYER/OW ER/S
MAP ROOK PAGE
Dwner Ir.•i .. noir ArTnr a':k nnwledpe
Ina: tni:, -ve rosnon5,t=le In, Th.
f r,I Iow'np
Contractor Owner
•FNnc:e R"m,yva! hv--�._/U
T—
f enCa H ularenwnl—byt��
,Tree Removal by I
tic—,lpanclor,_.lr"els by
;_Gas L_my R Permits b)•
INNotnr Venting by
Flartni; lion. up by t r
j�ontlrnp pv
. Tap 14 Fr_muc-bv--- - I
SALESMAN
MIDST INDICATE LOCATION ON THIS
SCALE DRAWING OF ALL ITEMS
LISTED REL.OW AND THE FOLLOWING
MUST RF. ACKNOWLEDGED BY
OWNER'S INITi AI,S.
f�- T
ISnepa of Ponl---•_-- -- 11147�-
i1Le- ngth'_-----��--
!Deptn of.Panon `�
!Filter Location
Board L rc: at. on ---.._—�--
•L.'pht Location
'L. adder Location ---I
,cf �'.•mp llnard Lnr: ationi --A�/A
[}hater Local inn -- _
{OeCking Ln.. t ion
'Coo,ng lnr:al'nr
IStnu Lncat'•,n - —
,tihap=f nl Sing.+
jL"ngth-Maximum !
Llangth-M'n'mum-------
!Depth. wx rmum
f-Dwoth _ Mnnmum
'.l'CA1'E THE }0L. LOW ING
ON
_L; RA IN11;iii:
:f•nol Sh aor R O i
y I
o
• •aSs &)cnn pmrtlns,onnnss-�I}=—✓-~�)
invi
• •,{: eSs DJ ,en::,nns
�•�c sh 'foes of SloppsT
:R(Mainlnp walls
end-Pn_nl
✓
vered Pato
A-
.r:Inctric son _--_-_---
��
use Btb--
000}:atpnce
—
Pool from
•-, louse A Prop. Lines
Utility One.
..__t^„' tit'I'ty Easements
p/'
•'-'ng S:r:icturo or
'!' •,ttn9Hd ST'l-C-tule no Prop..
/
C'17F,SS f.)AMAGF. ORUNOERGROUND
•I''% H cannot as"unwl
:•, :; :,nny rt„I'ty for damage to curbs,
driveways. cement slabs,
•awn''a. IawnS, traps, fences, re -
:r w' -911s, Sprinklers, telephone
"':er, conduits. gas lines or shrubs. '
when access is made through a
n:•'p.`dt-n:'� ":"'pert= it is understood
ihi:t you, the owner, have that neigh-
'.i:,:'S ne rmession and assume full
".9 APPROVES PLAN AND SPEC) -
(INS AS OUTLINED HEREIN,
11AS RECEIVED A COPY OF
AN.
... ... •._. ITIGNATUr1E
ADDRESS
W3
LEGAL DESCRIPTION - LOT —
Co4,P..J I—(
t
O
913
Decrc CocmQv�
P dqt
p►L
q ,
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------
CITY
TRACT'-----
1. .
A RE -INSPECTION E OF $30
Will BE CHARGED IFT APPROVED
PLANS AND JOB CARD RE NOT ON
THE SITE FOR A CHEDULED
INSPECTION.
.NO EXCEPTIO S!
CITY 'O F LA I NTA,
BUILDING & SA DEPT.
APPR ED
FOR CON . RUCTION
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