9709-019 (RPL)LICENSED CONTRACTOR DECLARATION
reby 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
rd1 a. .A,
ate ���� 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.
V) 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/ ry, Policy No.
t.!!J`�S G' 1�l:!,l V0 S�u�l 13•r'�1
(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
sg4ect to the workers' compensation provisions of Section. 3700 of the Labor -
4ode," Ishall forthwith comply with t ose provisions)
ate: G' of 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 conditions and restrictions set forth on his
application. '
1. Each person upon whose behalf this application is made & each person t'°'
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 r
& 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
tff`e above-mentioned properly, for i pection purposes. .
` xi
�ignature (Owner/Agent) .i�- , a .� DateA l'
PERMIT# CONTROL#
BUILDING PERMIT
556
DATE. VALUATION . S.
:vrSA� LOT .. TRACT
JOB SITEI
ADDRESS '•� 450 �i@nrs:��ii6'%R CE,
JAPN .- i64:;_1_ .00. .
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
,' .
C.ANCIA` 4.>yYigR9pY .
�Cr9SVE�0�GIV� U�r.IONJV
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USE OF PERMIT
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$333.60
LET. PE
SEP ®9 1997. E a + . �r�>:e r sF s � p�isallow
: 33.
ITYOF`—A°.�84�ifl9.0p��] i
RECEIPT
DATE r- ;
BY /
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Stee6>
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
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:
COURTYARD',
t
25* --0"
CONTRACTOR - cannot assume responsibility for GENERAL SPECIFICATIONS.
damage to curbs, sidewalks, drivewayscement SIZE
slabs, sewers, lawns.trees ' fences, retaining ' 17. 6- X 25
walls. sprinklers, telephone lines or shrubs. AREA 346 PERIMETER 74
When access is made through a neighbor's DEPTH 3-5
property it is understood that you, the owner, TILE CHOICE GROUP 3 SQ.
have that neighbor's permission and assume.full RB13. +6 -/SPA
responsibility. COPING CANT
DATE signature POOL CAPACITY 11,000 GALS
PUMP CAPACITY GPM
41
MOTOR HP HP
FILTER STARITE 300 SQ FT
CONTRACTOR - cannot assume responsibility for GENERAL SPECIFICATIONS.
damage to curbs, sidewalks, drivewayscement SIZE
slabs, sewers, lawns.trees ' fences, retaining ' 17. 6- X 25
walls. sprinklers, telephone lines or shrubs. AREA 346 PERIMETER 74
When access is made through a neighbor's DEPTH 3-5
property it is understood that you, the owner, TILE CHOICE GROUP 3 SQ.
have that neighbor's permission and assume.full RB13. +6 -/SPA
responsibility. COPING CANT
DATE signature POOL CAPACITY 11,000 GALS
CHECK VALVE
GASLINE BY S.D.C. FT.
POOL LIGHT 400 CLOCK 220
ELECTRICAL BY. S.D.C. FT,
AUTO CLEANER
CHEM. FEEDER
PLASTER COLOR WHITE
DECK BY OTHERS SQ.
RESIDENCE
STEP FT.
SPA SPECS.
SIZE 6 RAISED +6 -
TY LITE WATTS 100
-NIA
OF LA.
Qui
TRI LEVEL SEATS 22" 24" 27"
BUILDING & S DAMWALL 6 ''1 X 6 FT.
SAFETY DEPARTMEW DAMWALL-rOP TILE
ESIGNER
CONDITIONALLY SPILLWAY SIZE 3 -X ia -WIDE
ACCEPTED FOR CONSTR ANDY SPILLWAY X OPEN CLOSE[
IrON
UCTI DATE #JETS 5 UPER LOWEF
SUBJECT
TO INSTALLATION ASER'
f-20-97-
>ENTI RY
CANADAY & CANADAY
AND ALL APPLICABLE CODES AddresS: 47-750 VIA FLORENCE
ry
QLW LO
BY TRACTLAKE LA QUINT&QT# LOT 113
- - --------
Agodsoll
lot 113
POO/S
PALM DESERT TEMECULA
73-01.1 COUNTRY 28910 RANCHO
CLUB DR. STE F-4 CALIFORNIA RD:
PALM DESERT CA. STE 206
NOTE: LANDSCAPE AND FURNITURE 92260 TEMECULA CA.
'ARE SHOWN FOR ILLUSTRATION92590 -SWIM
(619)346-4032 (909)676
ONLY AND ARE NOT INCLUDED. LIC A-574127
PUMP CAPACITY GPM
MOTOR HP STARITE HP 1 .5
MOTOR HP HP
FILTER STARITE 300 SQ FT
FILTER RATE GPM
HEATER LAARS SIZE 400 BTU
TURNOVER 2 - HRS
SUCTION LINES 2-1.5
RETURN LINES 2
SKIMMER MODEL
CHECK VALVE
GASLINE BY S.D.C. FT.
POOL LIGHT 400 CLOCK 220
ELECTRICAL BY. S.D.C. FT,
AUTO CLEANER
CHEM. FEEDER
PLASTER COLOR WHITE
DECK BY OTHERS SQ.
RESIDENCE
STEP FT.
SPA SPECS.
SIZE 6 RAISED +6 -
TY LITE WATTS 100
-NIA
OF LA.
Qui
TRI LEVEL SEATS 22" 24" 27"
BUILDING & S DAMWALL 6 ''1 X 6 FT.
SAFETY DEPARTMEW DAMWALL-rOP TILE
ESIGNER
CONDITIONALLY SPILLWAY SIZE 3 -X ia -WIDE
ACCEPTED FOR CONSTR ANDY SPILLWAY X OPEN CLOSE[
IrON
UCTI DATE #JETS 5 UPER LOWEF
SUBJECT
TO INSTALLATION ASER'
f-20-97-
>ENTI RY
CANADAY & CANADAY
AND ALL APPLICABLE CODES AddresS: 47-750 VIA FLORENCE
ry
QLW LO
BY TRACTLAKE LA QUINT&QT# LOT 113
- - --------
Agodsoll
lot 113
POO/S
PALM DESERT TEMECULA
73-01.1 COUNTRY 28910 RANCHO
CLUB DR. STE F-4 CALIFORNIA RD:
PALM DESERT CA. STE 206
NOTE: LANDSCAPE AND FURNITURE 92260 TEMECULA CA.
'ARE SHOWN FOR ILLUSTRATION92590 -SWIM
(619)346-4032 (909)676
ONLY AND ARE NOT INCLUDED. LIC A-574127