0201-169 (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 f
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). '
( ) 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.
,Q) I have and will maintain workers' compensatlon 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 STATEl: Policy No. "a2194C410:714
(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'..WPection 3700 of the Labor
Code, I shall, forthwith comply with those. provision s6
Date: -`+ � Applicant
R �
Warning: Failure to secure Workers' Compensation coverage is unlawful and
-shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
.2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
'I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, 'and hereby authorize representatives of this City to enter upon
the above-mentioned property for, inspection purposes. t
Signature (Owner/Agent) �k �y'� Date )
PERMIT#
PERMIT
.�.`'BUILDING
DATE ;,.,_.:VALUATION LOT TRACT
+ �I�,�'i1fJ�fltr
JOB SITE
ADDRESS
7_72()VLk ri a1Z3-ylai
•.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
17480 Fn 17PrR'� h'Y:i; 03 06
95.2.2 !?C3NALDSOH RD,
CA 92780
UICKINE-VAI2E.if CA 9.2356
(' 60),249-61343 0, MA 4335
USE OF PERMIT'
P001, ANDIOP. SU?A
P0f1AP—i.?LA1rRA$p3:IEPS:Hald. fUt IN PLACE 3YP:YIkI6uTX41
FMECTiFFN. POOL pQUr.P`V9NYLKWCRMY3F NOT bT.LUDID.
VALUAT101i 118
XTEMAM.11) COST OV CONWAIRtra"ON
}'L.t`.N CHECK PIE 101-000-d39„f318 110,3130
: EC�tA1.kiCM LFEE -- POOL 1 df -09,0-4_.21.000 324,00
ib?, TRIC AL M,30� as POOL 10i -0d; 20.000 $43.00
3 $.C7l�IB.3'2UM ME .. POOL 101-00Q-419,000 $27.04
F
` JAN ? 4lifsi
CffY®FL►Qgpg i
JL
•
TOTAL PKIMYP :i IN 3.iUE NYW
� 5.:^.✓'.7.;ii�7i
RECEIPT
DATE
1,-'aF/.rm��
BY
AT FINALtD
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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 32
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
o
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping j=�
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 �J
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
Luceme Valley, CA 92356
(760) 248-6045
..
(760) 248-2919 FAX
Uc. #C-53-351673
m-
Sales Locations
s..
Bermuda ° Dunes, Irvine,
California City, Rialto,
Lucerne Valley.'
<<
1800 999-1811
CIFIC
3G'
AREA PERIMETER
a
DEPTH
LE CHOICE SQ_
RBB. -
COPING
o2Di f
PggL CAPACITY GAILS
PUMP CAPACITY . GPM
MOTOR WP HP
MOTOR HP HP
FILTER FT
FILTER RAIE GPM
HEATER SIZE BTU
TURNOVER HRS
SUCTION -LIMES
RETU N.LINES
•
SKIMMER MODEL
CHECK VALVE
GASLINE BY FT.
POOL LIGHT 'CLOCK
ELECTRICAL BY FT
AUTO CLEANER
CHEM.FEEDER
PLASTER COLOR -
DECK BY So.
DECK TYPE
STEP FT.
PA SPECS.
SIZE TRAISED
LITE WATTS
DUAL LEVEL SEATS
DAMWALL
DAMWALL TOP
SPILLWAY SIZE X WIDE
DATE,
SPILLWAY
CONTRACTOR cannot assume responsibility for
#JAS
damage to cubs, sidewalks, driveways, cement
slabs, sewers, lawns, trees, fences, retaining walls,
sprinklers, telephone lines or shrubs.
Name:Y10
When access is made through' a neighbor's property
It Is understood that the owner, have thatAddress.
' -7 -7o!O v
you,
neighbor's permission and assume full respo slblllty.
I
TRACT LLQ LOT#
SIGNATURE