0201-171 (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 Expo Date
Date z, ? 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),
( ) ;1, as owner of 'the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). I
() 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:
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. '
(VP ' 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:
CarrierT}Ai.'TS%),L%2b Policy No.,9-p-9iJ33�
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 provi`ons�of Section 3700 of the Labor
Code, I shall forthwith comply with those provision
Date: i t Applicant - -{
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 a conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application -is made & each person at
whose requestand 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 representative�of this City to enter upon
the above-mentioned property for inspectioriypurposes.
Signature (Owner/Agent)_ '.z •1'�" Date
MA
- =- ry j PERMIT#
UILDING PERMIT
..
DATE VALUATION LOT'g �'TRACT
JOB SITE
ADDRESS•%^;l�(a�bV��n..QAt
OWNER
CONTRACTOR /DESIGNER / EN INEER ,
x'74-80!:� 1 7.! it OIL A) 06
915.22. DOAAID003+f:x�.''�.
!f ry� ` CA 9278'0 ,
zUCTM- I OVAL) E CA 923 56
i : j I
`I Q� s1S• () tri;L =1.3
USE OF PERMIT
11 ` al ANDds)R `VA
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NOT A:fi1'CratMIM i
! 3'"O.40 'ft."*•
PF�F4k''E sum -WARY
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CONtSTR.iYCT11,3111{U - . _.. 101 cJ•�.18-000,{ tAi�a.f30
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?gl.t?rJIT Wo ni ` L, „ 101 0 41 a Q .o
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: JAN 2_4 11911
Cff YOFLAQUIMA
FMAN
s rriUA-TOT% itrPMR i.,ii i`(O C a T1. � An ;till '1
1 rpt l!
cm
RECEIPT
DATE �Iff
lJ `7
BY /
%
DAT(O/E �INAO�
INSPECT
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
Footings Z
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric Z
Underground Plbg. Test
Final
Gas Piping —
'% PLUMBING APPROVALS
Gas Test
Electric Final
aste Lines
Heater Final
Water Piping
—
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pads
0. K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation �=,_
Gas Piping
Gas Test
Appliances
Final G�
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:
VACATION POOLS & SPAS
9522 Donaldson Road
(�S
Pr
Lucerne Valley, CA 92356
(760) 248-6045
(760) 248-2919 FAX.
'
Lie. #C-53-351873
Sales Locations
e
u,,A41 M
Bermuda Dunes, Irvine,
California City, Rialto,
,__�__•,,
+ 4$ <<
Lucerne Valley
180099.9-1811
=�
6P
_-
.-----
N
SIZE IS" -3 -7
JU
EE
AREA PERIME
DEPTH 3' -S''
TILE CHOICE S _
i
RBB.
COPING
iPOOL
CAPACITY GALS
PUMP CAPACITY GPM
.
MOTOR HP HP
MOTOR HP HP
FILTER SQ FT
FILTER RATE, QPM.
HEATER SIZE BTU
TURNOVER HRS
;
SUCTION LINES
RETURN LINES
.
SKIMMER MODEL
CHECK VALVE
GASLINE BY FT,
POOL LIGHT CLOCK
ELECTRICAL BY FT.
AUTO CLEANER
CHEM.FEEDER
PLASTER COLOR
DECK BY -SQ.
'
DECK TYPE
STEP .. FT.
PA. SPECS.
SIZE 7 'X 7 RAISED LIB
LITE WATTS
DUAL LEVEL SEATS
DAMWALL
DAMWALL TOP
SPILLWAY SIZE X WIDE
ONTRACTOR cannot assume responsibility. for
DATE`JETS
SPILLWAY
#JETS
damage to cubs, sidewalks, drlveways, cement
slabs, sewers, fawns, trees, fences, retaining walls,
sprinklers, telephone lines or shrubs.
Name;
�f u � S
When access is made through a neighbor's property
understood
it Is that you, the owner, have that
'4
neighbor's permission and assume full responsibility.
DATE 17 D
`� s L- . L �R LOT# 15"
SIGNATURE
74L
TRACT