0205-155 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisioncof' ;;
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
5.43660 04O310I2t
Date Signature of Contractor
r
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
e:•- 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 SIAU RRA d Policy No. 3�OG4 b- I
(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 �a.ggree that if I should become
subject to the workerspcompel�"ation provisitos1of Section 3700 of the Labor
Code, I 4��I forthwith comply°h those p�ro�+slo>?s. 9
Date: App(icaat
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 Gity; and State laws relating to the building
construction, and hereby authorize representatives of this; City to enter upon
the above-mentioned property for i�r spectionapurposes'
Signature (Owner/AgerftJ
BUILDING PERMIT PERMIT#
Ind
DATE 7 VALUATION � LOT TRACT
JOB SITE
ADDRESS 79,.42:JLASM.s AS;
APN
OWNER
CONTRACTOR/DESIIGNEREN IINEER
CONTRACTOR
x 11 al y
LRU P-0 OL oIN,i;,TrRcrJ;mp
79.425 IA43 A NMS
41:-995 $0ARDWALK 0UY11: Abri
LA QlAZYM "" CA k251
P.&WLiMERT CA 922450
(u?)5688 9200 M41 6560
USE OF PERMIT
POCYL A�f'"DIOR SPA T'
POOTBR'A, AtAtt7b4SMAla3cYIMS S!; ALI. -bit 31x1 i?L,ACY, PRJO%? TO
POO)� AN D/OR SPA 110
MIUM T rim WAG&IRY
PSN Q + W FEE TOJ-C)00-4.39 319 ' SWIM
C'0148TRUC TION FEE 101-0W-418-000 $12q.00
MECHANICAL FEE -- POOL 1.01-000-421-000 SIM.00
EL;C; TR1C.AL, FS v- J500 : 101-OCO-420-t'> O &D$ oo
PL:UMBIH v -• POQIL•- 101-000.419.000
$0.00
LM P-PAUI) FXY18
1',IA`3. f 02Ga yw. ArL%n NO
CITYOFLAQUINTd►
"riIm
FINANCEDEPT.
RECEIPT
DATE �' // ;
BY�� fir -DATE
FINALED
INSP R
.f C.
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 _3/� 2
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
r
Equipment Location __3 / — •z
'
Underground Electric
Underground Plbg. Test
Final
Gas Piping
d
PLUMBING APPROVALS
Gas TestElectric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover _
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:
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MERRITT POOL CONSTRUCTION
� 47-995 Boardwalk Palm Desert 760-568-9200 l
lip j
12x'0\ POOL.
IS6FR I 26'0
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vtn1i11• 6'6
OLSEN RESIDENCE
a"T-e Co0c
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JLL:.'J!D. 2COl
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SPECIFICATIONS
Pool Sixe... 12' X 28'
Spa Si=e..7' ROUND
Pool Area ... 345 sq.ft.
Spa Area.... 50sq.ft.
Pool Perimeter .... 86ft.
Spa Perimeter .... 26.ft.
Pool Depth 3'6"X5'0"
Spa Eleva...+18"
Spa Jets....4 UPPER 2 LOWER
Lights -1/400 1/100
Autefill... M.P. Products
EQUIPMENT
Pump.StnRite Maxi II 1.5 H.P.
Cir. Pump..staRite Maxi II 1H.P,
Filter ... StaRits Modular300
Heater Teledyne Loom.EPL400
Timer... Aquaswitch
Oetldnq color... TOS
Square fact ... SW
Tile Choice.. _GROUP 3 T.B.S.
PEBBLE COLOR - T.B.S.
Mr. & Mrs. Joe
Olsen
79-425 Ave L.as Palmas
La Quinto(Alva 2)
l._D"'
LSAFETY DOVSTRUCTION
2 o�Z