0102-014 (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 # Lia Class Exp. Date
�y
Date s= 1 il,Ma1�a 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:.
'( ) . 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).
( ) l,. 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 Policy No.
(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
sub'ect,to theEApplicart—
Warnihg:
s' compensatlon rRvislons of Section 3700 of the Labor
Code I spa I,fcomply with thoset'p'r�ov ns��
Date:
Failure to secure Workers' Co*E; satton coverage is unlawful and
Y.shall subject an employer to criminal penalties and civil finesup to $100,000,
addition to the cost of compensation,"damages as provided for in Section 370
of the Labor Code, interest and attorney's fees.
IMPORTANT Application, is hereby made to the Director of Building and SFfetyy
for a permit subject to. the •conditions and restrictions set foo, is
application. ,
1. Each person upon whose behalf this application is made Si 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 i speCtio��pu�rp,9ses -
t <7
Signature (Owner/Agent) _ �. 1 '� DateT_.
10 v `1
' BUILDING PERMIT PERMIT#
—�-^
DATE ` 411 VALUATION LOT TRACT
RR f y y p
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CANADAY 0: CCaMPMY
HAS, HM&MIT dba ` ACATIOW POO
174-60 R 11171:1 UE. 01236
5522 D03MD 3014 RD,
Cid 92780
LUCEPNF VALLEY
CA 92356
(760)248430AS
Mllt 4,335
USE OF PERMIT
F'OO M /0R. APS,
B �'t:SirA.ONT LSt'-,�I,�t4:USIB1�22�;.IMRS SItW,LBEfl-d Ri ACE A T PRE
f�CJ3.�
KA4,ASTFR .PH3PW T0X.P00L XQUIPMENT EfiffaZ.OS11RE IS! NOT INCL DKO
POOL ANDIOR.R,%
4''a)"�c'l�c:(f'��:'SS�.[['�", H,,.yyJ.i�?�a?a.�lDY
�'F 414 CDZ�PX-M, d'l.�r�
C09tseq" tt.QC T10H'FEME 101-WO-Al84= $16x.610
moc!HM,41.: , �'.. i -• pom,, 503'i)0a,t 21a 000 U4,00
MOCTRICrALM88 - RSC QI: iid1- .0 � 2tt,t1(?A? $45.00
' 11
Bou 101
in zao1 -71
mall
Off TB-,'rGTAL COW MUC31014 AM. PLAM CE <1
87,
f• �;r�.t3e;3 �''Fi.�:-;�'�'a3•L) �':H: W
$6.6 C4
1119TAL PFUINTFFM DUE NOW
:c
3
RECEIPT
DQT,B,
BY
DPTF'-01 A!AD
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
S& 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
Set Backs
Steel
Electric Bond��o
POOLS - SPAS
—�
Footinds .
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Gas Piping
Encapsulation
_
-
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:
-
:.. 2. si12:52
7602482919
O
F
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Fo �df
VACATION POOLS PAGE 02
VACATION POOLS & SPAS
9522 Donaldson Road
Lucerne Valley, CA 92356
(760) 248-6045
.. '
(760) 248-2919 FAX
=
l.ic. #C-53-351673
Sales Locations
Bermuda Dunes, Irvine,
California City, Rialto,
Lucerne Valley
1 800 999-1811
RAI, SPECIFI�;ATION
U
I -Ake l,�+ pot i6"',
A RE-INSPECTION
THE APPROVED
WILL BE CHARGED
PIANS AND lOBR ADSCHEDUIED
E NOT ON
THE SITE FOR
INSPECTION.
NO EXCEPTIONS!
P
SPILLWAY SIZE
CONTRACTOR cannot assume responsibility for DATE SPILLWAY
damage to cubs, sidewalks, driveways, cement #JETS
slabs, sewers, lawns, trees, fences, retaining walls,
sprinklers, telephone lines or shrubs. Name:
When access is made through a neighbor's property
it is understood that you, the owner. have that Address:
neighbor's permission and assume full responsibility.
C
DATE TRACT
SIGNATURE
LOT#
7 !2? ?i pit?: 52 7602482919 , ``: VACATION POOLSY '
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PAGE 03 ' f(
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