0105-285 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm uifder 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
1`5 1 73 C:S
Date -Signature of Contractor "' i�
.. � "•.e j.?k� i
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 Uwner,bf ine property, am eXbIUSIVtsly contracting with licensed
contractors" to ,construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt uri"ter Section B&P.C. for this reas�n
Date ,! \ 1. Signature of Owner;
N.
WORKER'S COMPENSATION DECLARATION
Ihereby 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 Policy No.
S S, FUND 2A Q101
(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 provlslonsf Section 3700 of the Labor
Code,1 sha forthwith comply with tho e1prow`slons
Date: !� �^�' Applicant -.-1'>
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 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 representatives 6f. -;this City to nter upon
the above-mentioned property,fo onsp4ecilon purposes d
Signature (Owner/Agent i3"'-•�� ; Date, !+
W
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01415-2-M3 TRACT
Jots S1 FEAPN
ADDRESS
�"4sxGM& 4 vo t,1/0
474 VLA, .
OWNER
CONTRACTOR/DESIGNER/EN INEER
C`.`,AWeRDAY &; 00340AWY
KAL tA1.V,tT-rfON OnVAi77.110X PO4TLZ
174.80 L I'MI VL 4f) 06
9522 DONALMON.RIX
CA 92780
LUC"}MNE VATJXY CA 92356
(760YM8.6045 CST ?f 4335
USE OF PERMIT
POOL C NI O+I1r« HPA
)'£ eta d�'.4, tea: f?�RSd.Sr1�fiF'tT�Et� ikhl i GE, M P1,ACS AT Pig&.PLa3STYA,
NOT INICI.U' M),
1xOOL M EVOR,I)P . 14000.09 !Aa
troy l"93�`d ol��'�'�8:T7t°nom
P �W��p�'1 dye �+gq j �14�5"x":�fl;f��"wo
AFD Jw. SA Cr.l9!8dY.0..i'N.Y.`L a'6
MAN CHECK T01.1 101-000-439-3)8 $10130
C VIS'3'FtMCTIOM Flam, 101 -000 -413 -NO $162.46
MT3C,Yl=d.SaSQLyEYL .VhX -t-'10001, 101-000.421-000 $2A,00
K.� . ffflC'.cB,.1,,; .i EX ao POOL 101-000-420-000
1141' 1MUNO PIC, F: -} POOL. 101-M'10-419-000 527,00
TTc ANT) TIT—A.4
LW5 TIRE -PAID AM
,
MAY 2 3 2001 ,.. FM RT 0.11ES DUE now.
OUWA `
ti;t�uiCl qE.!'Y
RECIJPT
DATE
BY 'y.
DATE NALED
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
uO.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
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
� �v
COMMENTS:
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)
PW
.12111
{ 4,017, 7
VACATION POOLS & SPAS '
9522 Donaldson Road
Lucerne Valley, CA 92356
(760) 248-6045
(760) 248-2919 FAX '
Lic. #C-53-351673
Sales Locations
Bermuda Dunes, Irvine,
California City, Rialto,
CI
Lucerne Valley
O ` 1 800 999-1811
-{���.
970 % ; �/ f� ' J�-�
(/" l / �`—��--'l�
-
TILE CHOICE SQ.
RBB.
COPING
POOL CAPACITY GALS
PUMP CAPACITY GPM
MOTOR HP HP
MOTOR HP HP
FILTER SQ FT
FILTER RATE GPM
HEATER SIZE BTU
TURNOVER HRS .
-{���.
SUCTION LINES
RETURN LINES
SKIMMER MODEL
F
r
CHECK VALVE
.
�
GASLINE BY, FT.
POOL LIGHT CLOCK
ELECTRICAL BY FT.
• . ., .
AUTO CLEANER
:
CHEM.FEEDER
• A RE `INSPECTION FEE OF '$30
a
I
PLASTER COLOR
WILL BE CHARGED IF THE�APPROYED
DECK BY SQ.
Pl ANS'AND IOB-CARD ARE NO T ON.
,,
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-STEP
DUlEO
... ,..�. w �._..._ _ .... .w., • . - .. .. . FOR A SC _
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_
FT
�...... __.... ,:..,.."INSPECTION.
,
.. �.aSFr .....
- NO EXCEPTIONS`
LITE...
MATTs
t
DUAL LEVEL SEATS
DAMWALL
-
DAMWALL TOP
CITY OF LA QUINTAI
�
SPILLWAY SIZE X -WIDE
�.. _
� SAFETY DEPT'
a m
CONTRACTOR cannot 'assume responsibility for
DATE
SPILLWAY
#JETS
..BUILDING -
damage to cubs, sidewalks, driveways, cement
APPROVEDf
slabs, sewers, lawns, trees, fences, retaining, walls,
sprinklers, telephone lines or shrubs.
Name:
FOR CONSTRUCTION
When access is made through a neighbor's property
` A
it is understood that you, the owner, have that
neighbor-s permission and assume full responsibility.
Address:
• DATE
�
-
:
CIA
i
I DATE,TRACT
LOT#
1 SIGNATURE