0006-009 (RPL)LICENSED CONTRACTODECLARATI
R ON -y
I hereby Airrr:°.under penalty of perjury that I am licensed under provisions of
Ch' pter 9 (commencing with Section 7000) of Division 3 of the Business and
� pfe?hionals Code, and my License is in full force and effect.
nse Lic. Class Exp. Date
y3;412 C53 `p 7{Jj '1;�/t
Date ` Ci0 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.
(jO.'l 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 STATE FUND Policy No. 229.0012ns
(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 thosg,7provisions._f
Date: 6-'7- 1'Q Applicant r'�=V• �.`'�—�(' A.
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 urposes.�,�f
Signature (Owner/Agent)
_21 t _/ - (�L - - ( Date % C_
BUILDING PERMIT PERMITk
DATE VALUATION LOT, TRACT
(*AM= $10000100
JOB SITE
ADDRESS n_94,�
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
SUSi .qWLYdCH
Af DkRF EE CC9N�§a MUCi`10N
78-34.5 `YIAV6ORM C E
74,360 VE -AX ORD
LA QTJINrA C A 92253
k AuA DnEir CA 92260
(760)773---3293 - Me 5302
USE OF PERMIT
POOL AM/Old SFS,
POOL & SPA ONLY-At.ARPAS/;iA"IBRi SHALL BE fm PI ACE AT PRE
PLASTER 3.A-SPECt'ION
POOL ANWOP,SPA Imo:
X9I13W.i7 D 05ST OF C0116MUCTIO7d
Ai3,CFiki.()(D
PERMIT FEE SUMMARY .
PLA14 C HF -CK FE 101.000.439318 $76,05
CONSTRUCTION ME 101-000-415-000 $11%00
MECHANICAL FEE -- POOL 101-000-421-000 $24.00
ELECTRICAL FZZ -= BOOL 101-000-420-000 1W5,00
PLUIv D 140 EPEE --' POOI, 101-000-419P000 520.00
1,
9L1:13 -TOTAL Ct>1bfM'RUC°ri-ON A1M PLA14 CI:Wi K
$259.05
S PRR PAM I+>a3s.�1
$0.00
'I»OTAI. FNITt1V TISSDUE BVW
$t ,46
RECEIPT
DATE
BY
DAT
FI
LED
INSPECTOR
INSPECTION RECORD
.`ERATION
DATE
. INSPECTOR
OPERATION
DATE
INSPECTOR
' r 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Footings
Electric Bond
Main Drain
_�/ e6
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
Z
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:
CONTRACT OR cannot assume responsibility for GENERAL SPECIFICATIONS
dam ak,etc, curbs sidewalks, driveways, cement
slabs ewers lawns trees, fences, retaining SIZE 7
r 3 fJ
-+ walls, s�nl iklers: telephone lines or shrubs. AREA PERIMETER
When acc-ass is made through a neisihbor's DEPTH
P prop er�i• is understood that you, the owner, TILE CHOICE SO.
' have that neilzhbor's permission and assume full RBB. I'6
i.
l COPING .1�' t:tsr
reSpOnst �
DATE _� .j "' 7� t . signaturE' l POOL CAPACITY GALS
:.
PUMP CAPACITY . GPM
MOTOR HP 4' -; W'4 HP
I
,': S G MOTOR HP HP
a ir'v p"J FILTER f•{" �Jti-,4 -3000 SOFT
FILTER RATff / -L'o GPM
HEATER'. - 'Ao IZE �?BTU
,
TURNOVER HRS
SUCTION LINES .: Z
RETURN LINES
+ ! i SKIMMER MODEL %,•e f.trJ
CHECK VALVE
A ft �ry.ra.E�, �ja
�
------. GASLINE BY FT_
t
POOL UGHTA,ti.P,+t'h✓CLOCK
i
ELECTRICAL BY.
' 1 I AUTO CLEANER -,4ZjJ,2So ' 0141,_f
CHEM. FEEDER n� D
PLASTER COLOR17
r
t
DECK SO.
-"- _ ,.. ,. _ DECK TYPE Cc
STEP
SIZE RAISED
r l LITE VE 5 WATTS
TRI LEVEL SEATS
DAMWALL X FT
DESIGNER DAMWALL TOP
t G,4'-^ SPILLWAY SIZE X •WIDE.
} _ CLOSED
DATE SPILLWAY OPEN
r t SPS"��rj �r_L#JETS UPPER LOWER
00Name: Su.-sA P-)Ly t-)
' Address:%69 v i c,.,C
c
ALDERETE.
r POOLS •SPAS • LANDSCAPE
b 74360 Velardo Drive Wk. (760) 773-3293
Palm Desert. CA 92260 Pgr. (760) 833-7632 '
Stole Lica 331412 Fax (760) 773-3293
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