0204-018 (RPL)U)
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LICENSED rONTRACTOR DECLARATION
I hereby affirm uncl6genaltq 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 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 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).
(-rl am exempt under Section , B&P.C. for.this reason
Date " A Signature of Owner A
r
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.
(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 forthwith.comply with t., ose•provisions. ;
Date: C� Applicant / F f s , . J. 0_....•,
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 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'Ignature (Owner/Age"nt)'-` /"/ -' ._ -�"�^ `r Date h '
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PERMIT #
`- BUILDING PERMIT
���; ���
DATE VALUATION LOT TRACT
JOB SITE
APN
�ey �a�+ •��
ADDRESS 79„4,50 DVSXf Ri {. i`.1i5°.k�+LVd. DWW,
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SC'alTRUSSELL
MJ1''R PAM DER
79-150)DE=,T'M.WJ--AA DRIVE
LA QTJIa rA CA 922,53
4 � _ CExdi
USE OF PERMIT
POOL,0WIC'Ri. SPA
PODUSM A1JUZA1S/RA,€dPJFRS SHALL BE M PLACIE, AT PI'S-PLA:s' EIZ
1? OPiX i 101.1. *POOL KQUIPMEENT Y C(:. WR.E NOT NOLU'DED.
VALUATION U11
E1r," $'AilMI COS -r OF COnSTR JMOR
MOW=
pw"r JIM, NUMMARY
PLkA CHECK ME 101.000-439.318 505130
C:ONSTAZLICTX014 .FIM 101-000-418-000 $162.00
C'H•t4►NIC.AL FEE >- POOL, 101-000-421-0010 U4,00
I9LbrCTR1i;,tJ , Y'e - POOL 101-000-42 0-000 $43.00
PIXIMBIWO M? -'- Pool., 101.000-419-000 $27.00
.y
ML, .1 • C.ON-2,TRi` DIS AWD PLAN' CRECK
$263,30
coy ��1� •�
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BY /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 Controls
Party Wail 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
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
2
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:
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SCOTT AND KIM RUSSEL
79150 Desert Stream
La Quinta, CA 92253
GENERAL NOTES
Pool size: 28'x 14'
Pool Depth 3'-5"-3'
Pool Water Surface Area 306 sq.ft
Spa size: 7' Diameter (18" raised)
Spa Depth 40"
Spa Water Surface Area 38.5
Perimeter 1051
.
HAYWARD 400,000 BTU heater,
400 sq ft filter and two
2 HP Northstar Pumps and motors.
300 watt light on pool
200 watt light on spa
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATEY3 o Z BY
Scale: 1': 10'
CITY OF LA QUINTA PUB-CONTRAC��T,1� LISTJOB ADDRESS79-15() P� PERMIT NUMBER OZ -0y-01 OWNER C )3SA.L) BUILDER n wN6 /- &/I
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to *eY
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the void
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade / Classification
Contractor
State. Contractor's License
Workers Com ensation Insurance
17 City Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C-8)
FRAMING (C-5)
STRUCT. STEEL (C-51)
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(19-7/7
MASONRY (C-29)
PLUMBING (C-36)
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14
36-6SS
d31/0
LATH, PLASTER (C=35) '
S
C- 53
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DRYWALL (C-9) .. :.. ;
/LSOr-a,,, CQ puro
Ou is - n 5oq 14 6
HVAC (C-20)'
ELECTRICAL (C -10)Q
-P, -n r L,(
ROOFING, (C-39)
SHEET METAL IC 43)
FLOORING (C-15),
INSULATION (C-2)
SEWAGE DISP. (Q,-42):' ,.
PAINTING (C733)'
CERAMIC TILE (C-54) .
CABINETS (C-6)
FENCING,(C-13)
LANDSCAPING (C-27)`:::
POOL (C-53)
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