9910-224 (RPL)LICENSED CONTRACTOR DECLARATION
' I hereWaffirm under penalty of perjury that I am -licensed under provisions of
-hapter 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 /pate
s51673 C•153 i11C3112 Of
/ate k It 64 6ignature of Contractor—A,
v �
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
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 Policy No.
STTrx'.1L 229^79NlTWI19Y
3f
(This section need not be completed if the permit valuation is for $100.00 or less).
() I cepfy that in the performance of the work for which this permit is issued,
I shall p6t employ any person in any manner so as to become subject to the
workefs' compensation laws of California, and agree that if I should become
�fil
subject to the workers' compensation provisions of S n 3700 of the Labor
C,,ode, I shall, o hwi h comply with th se pro i�of�s.ILI
"bate: ° • `applicant
r. e
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.,,) agree to comply with all City, and State laws relating to the building
construction, and hereby authorize represen atives f this City to enter upon
/thabove-mehtioned property for inspe io /purp 's s.
7MQ
tiSignature (Owner/Agent)r f o Date � � J
BUILDING PERMIT PERMIT���
DATE VALUATION S1,K,(f)Q,Q0 LOT / TRACT
10 J. 1 /4
Job S1 I E
ADDRESS 47-610 VrIA AWNI TANA
APN ..
OWNER
CONTRACTOR / ENGINEER
CA YT COMPANY
VA/MrydN FOOLS -
6570 J0.LOnAOL1.0YRN, SUITT-, 203
1DESIGNER
9522D^VfJtON A..0,AD
SANTA ANA 4.A 9,1705
1,i.fCF"fR VALL,1:V CA 1.r2356
('760)2494M5 ('.':.ATU .4335
USE OF PERMIT
ij()GI, SaSPAvNLY. i�iW € ivaa� r� �E t .S ` 1�1. �% ilii ;til AC.•& �►T
.1 OM4 ANDOR .^g. V sk 15,000.00 u
a u�a. NIA 0.Iui +�.�Mk Y. ��b+. v..'�,rSMNTRI YJYq Ss 8•'rl. N
s..,bft0'o
PERMIT FEE SUM,'4G04
P1 AN C.2•iEt,:K F7.1h
rc9.�i�d "Eit°1•i.f►c `r! r;.►0141F-00 $33h24
�l001.
.4..lE.►00
A1.Fpp1 ))Ap,,IC^^yy. F*E'21 P ML 1101'ON-421-000
{
ftM77RICAL VW -- POOL OL 0.1.040-4.20.1000 $45.00
P1.dJart�rc�;r°��;•-_tz. 1.11-0011_�1�-of1� ;e�'�.f3n.
c .�;�.�
•,r
r.51 i"[i- S't')7 All , C'O'niSTRI 7MION-AND KAN (11 F N
$363.30
LESS PRE-NUD FEES
$0.00
'TOTAL P.ERNIFI'VEKS M.KNOW
$30138
RECEIPT
DATE
By
DqE[FINALID
INSPECTOR
r
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
T
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
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:
�1 VACATION POOLS & SPAS
9522 Donaldson Road -
��-o Lucerne Valley, CA 92356
PI KcDo (760) 248-6045
14 i2 (760)-248-2919 FAX
ljQ ,i 717TLic. #C-53-351673
A RE-INSPECTION
FEE OF X30
_ Sales Locations
WILL BE CHARGED IF THE APPROVED
8 PLANS AND 10B CARD ARE NOT ON Bermuda Dunes, Irvine,California City' Rialto,
` THE SITE FOR A SCHEDULED
Lucerne Valley
ON.
INSPECTI
✓ 1� 3s t NO EXCEPTIONS!
1 800 999-1811
G N-FP CIFICATI®N
SIZE J ' X
AREA PERIMETER
S DEPTH 3 '/a - S'
TILE CHOICE SQ.
S., o I\ _
_ , RBB.
.. C COPING
POOL CAPACITY GALS
cAf p ' -"� PUMP CAPACITY GPM
MOTOR HP HP
} MOTOR HP HP
FILTER SQ FT
t a FILTER RATE GPM
HEATER SIZE BTU
- _ I TURNOVER HRS
- _ < < " SUCTION LINES.
' `aNV�� RETURN LINES
`R a
. SKIMMER MODEL -
- CHECK VALVE
1 �e
v eGr GASLINE:BY FT.
ev' .
POOL LIGHT Sop CLOCK
Tso - tis
_ ELECTRICAL BY FT.:
_ AUTO CLEANER.
-. CHEM. FEEDER
.. - PLASTER COLOR
- DECK BY, SQ.
OF LA QUINTA DECK TYPE
of C STEP FT.
L nJ� ; B ILDING & SAFETY DEPT. sPA SPECS.
SIZE RAISED (oAPPROVED
LITE r5 WATTS
„ -� Iv OR CONSTRUCTION DUAL LEVEL SEATS -r 5
DAMWALL G `�
BY DAMWALL TOP
DATE o SPILLWAY SIZE t ''X lu " WIDE
E CONTRACTOR cannot assume responsibility for DATE SPILLWAY 1
" damage to cubs, sidewalks, driveways, cement #JETS S
slabs, sewers, lawns, trees, fences, retaining walls,
sprinklers, telephone lines or shrubs. Name: S I a � +C-V—
a When access is made through a neighbors property
it is understood that you; the owner, have that Address: y (D 10 U °� MON
neighbor's permission and assume full responsibility.
DATE
TRACT Q•LOT# �ak.e �.d68 5
1Lj y 4 SIGNATURE