9910-128 (RPL)LICENSED CONTRACTOR DECLARATION
'_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
3511673 C .-53 hI./�1iN
Date d r,� S gnature 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:
( ) .1, 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 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�N,::f Policy No. 229" UN, 1Y 19 344
(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 notremploy 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* ose provisions—
"Date: t tg 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 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, indemnity
& 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
eaabove-mentioned property for
rryinspection purposes.
�SI"gnature (Owner/Agent) ` " Date tg` i rf
BUILDING PERMIT PERMT#
DATE 10122,41..99VALUATION 11.155AN, LOT TRACT
JOB SITE 7F1-%10 VIA. �k LOR&�T� CE'
APN ., _.
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
15i0 BROGICHOi.,i.,041 i.)xi.vr., sUC1'1.: 2.os
91522 i.X1N11LDSONT ROM,)
SAVW ANA CA. 92705
LUCERNR VAUISI Cts 32:4.56
(76024.8,-6045 C33L* 4115
USE OF PERMIT
POOL tl t+i T OR ZSPA.
POOL & fiRK ONLY. ALAf4.,wi3ifjAPJR'.NtS S1kx11.,i. 69 IN PLACE &
:Pitt i=1.A5`) Ef{ tPf`ti1I�t.0 f'iifFi,
P001, .t►ivWOR SPA, i 5,{Itilw@ s , ti
'E:,SYMISIX.01113) _11.1 loT of, WN;MA1:1LTI N
3:.1000110
t_,°{tyJ�/MS'1'RtfC;,1i'y€G3t�FHil.
cynF�\y'S�!%���^G.v T'�� �. (�{%\k✓]„ �tl�"T i}i1.���'!S'"l.f}�?.d 1�1.Zf.�)
i.i t C`1tfC"es.A, FrIX r. POOL 101.9w_1410_000 $15.€Itf
k'LCik+01,140 fa. — iiC�c/:t I.CI.); ijt}C!-�'i-it(1f1 tl :i Iht
S T -' y"9°i r�i; :' ►t+s� f Li j(,:' j(?)rJ ND Pf,-?7tNtg!�?y1�EiT,`3d
�;?.YS�Sti Cha
1 G
';i ta'1'AI, kftMMI'I k'KAW 0119, NOW
RECEIPT
DATE
BY
D T FINA
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 8 Controls
Party Wail insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
�P?
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
�� 1
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
/
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�%�Z ��
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)
/ VACAT'IOh POOLS & SPAS
9522 Donaldson Road -
' ✓ Lucerne Valley, CA 92356
(760) 248-6045
�. (760) 248-2919 FAX
Li -..#C-53-351673
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED Sales Locations
PLANS AND JOB CARD ARE NOT ON Bermuda Dunes, Irvine,
- THE SITE FOR A SCHEDULED California City, Rialto,
- INSPECTION. Lucerne Valley
- NO EXCEPTIONS!
1'800 999-1811
GEl�TERAL SPECIFICATION.
SIZE y' x a s'
AREA PERIMETER
DEPTH
` - is _ • _ • ,�� � .. �� / TILE CHOICE SQ.,
RBB.
r COPING _
- • POOL CAPACITY GALS
PUMP CAPACITY GPM
MOTOR HP HP
` MOTOR HP HP
" FILTER SQ FT
FILTER RATE
GPM
HEATER
TURN6TU
OVER HRS
SIZE
• � ,{-• ,� - .. SUCTION LINES .
RETURN LINES
SKIMMER MODEL
. - CHICK VALVE I
GASLINE BY F T.
4
,� CITY O F LA QUI NTA POOL LIGHT CLOCK
�p �, y ELECTRICAL BY FT.
7 - - _jt! BUILDING & SAFETY DEPT. Auro CLEANER
CHEM. FEEDER
APPROVED PLASTER COLOR Q
FOR CONSTRUCTION DECK BY
DECK TYPE
STEP FT.
_DATA I6 2 a. BY SP. -1 SPECS.
ID SIZE 7 RAISED �
1 - LITE WAT I S
DUAL LEVEL SEATS � S
.i
DAMWALL 6
� � DAMWALL TOP -r
E SPILLWAY SIZE 3 'X /8'/WIDE
DATE SPILLWAY' Y e -
I • - - ` CONTRACTOR cannot assume responsibility for I ,-
�. mJ ITS .5'
i damage to cubs, sidewalks, driveways, cement.
u �, ; i - ✓ / - =�slabs, sewers, lawns, trees, fences, retaining walls,
�E. ( ! " `' sprinkler, telephone lines or shrubs. Name:
�%` ' When access is made through a neighbor's property
it is understood that you, the owner, have that Addr'ess.-
G. �� i neighbor's permission and assume full respo^sibility.
� City:. rV
DATE TPACT LA lie- �� LOT# i
- �-1 SIGNATURE Qu iv