0311-054 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby 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 l x Signature of Contractor•.�i-
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() 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 Se tion 3700 of the Labor
Code, I shall forthwith comply with those=provisions
Date: /W i �I Applicant—
Warning:
pplicant �'
-�
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 in+spection pur-oses.
dd 1
Signature (Owner/Agent)
- • -BUILDING PERMIT PERMITq
DATE r. VALUATION LOT �Z.11a TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
6852 iii. VEi MACH CIRCLE
22%') F. ".%&I ?,:31CRD
HUM N s' 'M BEACH CA 92CA 9
xdZM,, Sk'1<': WC3 S CA. 97,26T
USE OF PERMIT
Tt(-s .x, A'hTt)/0R SPA
P0011SP A, b 11r. 4' 0AC'sf:3 1 : TA1.gDAi?_iiD.
AILARXt*lt3A1i_i3IER 53HA ,L H, NPLACI,AT I*1WPLAOTEH, N., P EC'!'LY,N
n n n r�
4 IF ALL 6190 IV
18 1003
ROO!., A1+ID' O.rc SPA. 19,991n.o us
C;TY
GF LA QUINTA
FINANCE DEPT.
.1?+wti"IDTAVOU) SMVr ("Ar 00RITC1 0IN
i'
��kn)Cs�3.CDtS
r�rana� Climm n
C014S RUMON. ,Ery 101-000-418-000 00.00
mv,c4'i.d)cc.m4 rn .. rOOL 101.000421-000 324119
Lt'LY,C:Tk1C Jul,, :'T7Z •- P001.. 101-000-420-000 $015,08
PLi fMPRIC VER -- POOL ) 01-000.4 ;'-0 0� :�
i3F,-T[tYPa�"L�s��Ol�l�i"i Lfc"i E.:tPr.AND�1y.���L'�'i
RECEIPT
DATE
BY 1
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
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam _D
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
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:
BUILDING & SAFETY DEPT.
w APPROVED
FOR CONSTRUCTION
DATE �-�—
P/L
LAWN
PA
G/E
60k
r
l�
L
11'1
10'.QUARTZITE SPILLWAY
It 18"
b'8"R•
pool
-51. 17'10 --.. - .. 3 \N .
1
14'6
i
SPA SET @ «18"
`FIVE BACK JETS
$a STUCCO EXT.
t'
X7'0 i
i
/ENTRY STEPS
n• . a
n 23'4
19'10 23'10
decking
25,9 31'0 '
----------------------
PA �o ufi EQ
1 light switch W a- ( e +
--� loggia 1 F
sleeve all planters H j
P,
GA TE I
bobcat access
VAN WAGENEN RESIDENCES
80-872 HERMITAGE WY
LA QUINTA CA
REVISED 9-11-03
11/05/2003 16:42 760-320-3667 SAUNDERS ENG PAGE 02
11/05/2003 12:04 7765111 MONARCH PAGE 02
FAIRWAYS ASSOCIATION
November 4, 2003
Mr. Jay Van Waggenen
6852 Sliver Beach Circle
Huntington Beach CA 92643
RE: 80-872 Hermitage
Pool and Spa
Dear Mr. Van Waggenen:
co�
On October 27, 2003u submitted subject ns hle fol orui g� nditiq ed and
approved the plan y
• A wall is required surrounding the equipment.
Landscape plans to be submitted following or during pool and spa
construction.
.If you have any questions please contact me.
Sincerely,
ancy Du e, CLAM
Association Manager
WIMP
CC, Canyon View (pools
Post Office Box 1658 . La Quintan C4bfom.ia 92253 1Phone (760) 776-51.00 • Fax (760) 77 6-5 111