05-1725 (RPL)P.O. Box 1504 � VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253INSPECTIONS (760)777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: OS-' Date:.
Applicant:
Applicant's Mailing Address:
C01V 7,C4 C, 7 07C
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
MA
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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
�Ebde, and ss Licgpge is in full force and effect.
/License Class !3%D l!/ License No
v J
r,•yate /� � Contractor
OWNER -BUILDER DECLARATION_
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to -
the Contractors' State License Law.).
U I am exempt under Sec. , BA P.C. for this reason
Date
Owner
WORKERS' 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
issuedy workers' compensation insurance carie nd olicy number are:
Cam _ �:%fri� -- A Policy Numbe/ �0`Y34S
_ 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 Californi , 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 those pr isions.
Applicant
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name „ /
i
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and ereby authorize representatives of this coun enter upon the above-mentioned propert r inspection purposes.
Date �� Signature (Applicant or Agent):
------------------
-----------------------------
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Application Number .
. . . . 05-00001725
Permit . . . . . .
BLDG POOL PERMIT
Additional'desc
Permit Fee . . . .
162.00 Plan Check
Fee
10.5.30
Issue Date . . .
Valuation
. . .
. 15000
Expiration Date
11/0.1/05
Qty Unit Charge
Per
Extension
BASE FEE
45.00
13.00 9.0000
THOU BLDG 21001-25,000
117.00
Permit . . . . . .
MECH POOL
Additional desc
Permit Fee
26.00 Plan Check
Fee
6.50
Issue Date
Valuation
. .
0
Expiration Date
11/01/05
Qty Unit Charge
Per.
Extension
BASE FEE
15.00
1.00 11.0000
EA MECH FURNACE >100K
11.00
Permit . . . . . .
ELEC POOL PERMIT -RES
Additional desc
Permit Fee . . . .
45.00 Plan Check
Fee
11.25
Issue Date
Valuation
0
Expiration Date,.
11/01/05
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 30.0000
EA ELEC PRIVATE SWIMMING
POOL
30.00
Permit . . .
PLUMBING
Additional desc
Permit Fee
33.00 Plan Check
Fee
.8.25
Issue Date
Valuation,
0
Expiration` Date
11/01/05
Qty Unit Charge
.Per
Extension
BASE FEE
15.00
2.00 6.0000
EA PLB FIXTURE
12.00
1.00 3.0000
EA PLB WATER INST/ALT/REP
3.00
1:00 3.0000
EA PLB GAS PIPE 1-4 OUTLETS
3.00,
----------------------------
Special Notes. and Comments
POOL & SPA ;ONLY. ALARMS/BARRIERS.SHALL.
BE IN PLACE PRIOR TO
PRE -PLASTER
INSPECTION. EQUIPMENT
ENCLOSURE NOT
INCLUDED IN PERMIT.'
Fee summary Charged Paid Credited
Due
Permit Fee Total.
266.00 .00
.00
266.00
Plan Check Total.
131.30 .00
.00
131.30,
Grand'Total
397.30 _00
.00
397.30
i�
. 7BJn
Pere #
05
X Project Adarss:� �,
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Cit} ' La Quin.ta-
Buficffnc,,.
ez Safety Division
P.O. Box 1504, 78495. Ca1ie Tampico .
Ia Quinra, CA 92253 - (760) 777-7012
"Building Permit Application and Tracking Sheet
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Address:�l^,�11 1l1 /1 , .V1r✓P�-�-r�
Legal Description:
Cin•. Sr. Zip: La 4 a a.25
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Address_ �lJ`2� 1 ri,! ! II :) ac) b
elephone: 1903 —Q&30
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State Lic..: U i
City Lic. ': i b,53
Arch_ Engr_ )resigner.
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City. ST. Zip: .
Telephone:
State Lic. 4•
Name; of Comer Person: Y
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Construction T�. Pc: %Occu
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Sq. FL: IStories: � Units:
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Estimated Value orProiect:� "
APPLICANT: DO NOT WRITE BELOW THIS LINE
Submittal
Req'd I
Rec'd
TRACKING
PERMIT FEES
Plan Sets I
Plan Check submitted
15
��JS
Item. ' Amount .
Structural Cales: i
Reviewed.,reach- for corrections
Plan Check Deposis
Truss Cales.
Called Contact Person.
Plan Check Balance
Mtic '_a Calc!.
Plants picked up
I
Construction
Tlood plain plan
Plans resubmitted
I
Mechanical
.Grading pian
'_" ReNiciv. ready for corrrctionsfrssue
Electrical
Subeontaetor List
I
Called Contact Person
Plumbing
'G'raar Deed
Plans picked up
S.M.I.
'H:O-A..Approval
'Plans resubmitted
Grading
I'V H OUSE -.
I
"Review. read-,• for corrertiotaitssue
Developer Impact Fer
Planning Approval
Called Contact Person
A_I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fets
a
Total Permit Fees
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POOL SPECS
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ROCK POCKETS:
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FILTER;
POOL PUMP;
BOOSTER PUMP:
HEATER:
TIME CLOCK:
POOL, CONTROL,
RETURN INLETS;
SKIMMER:
AUTO -FILL:
GAS LINE:
STUB OUTS:
CASCADES;
SPRAYHEADS;
POOL LIGHTS:
SPA LIGHTS:
PLUMBING SIZE:
STUB SET EQ:
GUNITE
POOL BENCH:
2nd STEP:
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STEPS:
STEPS FACE:
SUB BASE:
VISQUEEN:
BANDING:
STAMPED:
RELEASE:
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COPING TYPE:
RBB FACE:
SPILLWAY:
STEPS:
P/L EXT WALLS:
PLANTER WALLS:
RETNG WALLS:
EQ WALLS:
GATE TYPE:
R&R GATE:
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SIZE::
BBQ MODEL:
TOP FINISH:
SIDE BURNER:
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PEN LIGHT:
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PLAN FOR
VUKOVICH_RESIDENCE_
ADDRESS: 51.245 VIA SORRENTO
LA QUINTA
LOT#95
REVISIONS:
(1) ____ DATE:
(2) DATE:,-----
(3)
ATE:_-__(3) DATE:
Date Printed 1/811= 1' SCal
09:02 PM 05/04/2005 111111113
Drawing by; JUDY