0401-013 (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 # Lic. Class Exp. Date
Date i V Signature of Contractor
OWNER -BUILDER DECLARAI1011 •.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason;
( ) l,.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).. ' r
(,) ; I,' as. owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & I Professionals
Code). •
O
ram exempt under Section B&P.C..for this reason
Date Signature of Owner .
Q WORKER'S COMPENSATION, DECLARATION
EL
C) I hereby affirm under penalty of perjury one of the following declarations:
Lo r H O ( ) I have and will -maintain a certificate of consentto self -insure for'workers'
X` u1' LLcompensation, as provided fors by' Section 3700 of .the Labor Code, for the
O J Q' performance of, the work for which this permit is issued.
m Q V O: I have and will maintain workers' compensation insurance, as'required by
D,U. Q , Section' 3700 of the Labor Code, -for the performance of the work for which'ahis
2 L F<:
p6rm"it'is issued. My workers''compensation'insurance carrier & policy no. are:
�= Carrier ��,4!'`?' A13�:p�� �ii'F#I Policy No:
00./E' .. .
�i `J
' Q•.. (This, section need not be completed ifthe permit valuation is for $100.00 or less).
r •(`)° I certify that in the performance of the work for which this permit is issued,
�} l4Aall not employ any person`in any manner so',as to become subject to the
r . workers' compensationr laws of California; and agree, that"if,l should become
subject to the workers' compensation provisions of Section 3700 of'the Labor
Code, I shall forthwith comply with those'provlslons:
r. Date ,: • i / 1 M a { Applicant, i r'- i�+. f rl
® Warning: Failure to secure Workers' Compensation coverage is unlawful and `
shall subject. an employer to crimi'naf penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for iri Section 3706
Of the Labor Code, interest and attorney's fees
.:IMPORTANT Application is hereby made4o the Director of Building and. Safety
for &;.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 puYsuant to_
any permit issued as a result of this applicaton•agrees to, & shall, indemnify $
f•+& hold harmless the City, of La.Quinta, its officers; agents and employees!'
` .=
iF14n
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 sucha
permit, or cessation of work for ,180 days will subject permit to cancellation .
l certify that I have read this application and state that the above information Is-
-correct... I
s—
•-correct..I agree to -comply with all City, and State laws relating to the: building �
construction, and hereby authorize representatives of this dit to enter,upo
the above mentioned property for inspection purposesw�.,
Signature (Owner/Agent) '�' f "` )' Oil, Date
` BUILDING PERMI PERMIT#
.w
D"ATE M" / VALUATION `-�L•OT, TRACT
JOB SITE JAPN
ADDRESS
A
OWNER
CONTRACTOR / DESIGNER / EN INEER
r�1� 14CL�,.TJ�C�IEiT,.W
i3f.,"I t�: 1Y1 1�OOi..S; A19D SPA
7 8.910 VIA �T.�I'C',ANA
4.6880 �R!ldU�iTE�tJ' �OV� i? VIE X194
IA QTtWTA CA 92253
�t�l .110+�d'(�?"Gr€ LS CA 92210
'�i ().345,1376 CUff 6697' ,.
1
USE OF PERMIT
PObc,,/�? D10k.RPA -
PDOUSPA, FIB- �(�i2�SIZ21-9R1�199:5a. ,Ft:'LARIV;5/S�3.T2.,� ERS SHA.1-1 BE
W P)�€10E ATPRE-PLASTER FINSPE ► [Ord; FQIxiP 31:TdT 1!"T1 1 SLIf;E� 13t7`� r '
INCLUDED
Pr30i AND/OR SPA 2�,i►t�D,tI1 ul
,
E.MMATLM COW ON? CONS M, M11011f
L';4 ,1. IT,' mg—V &Om',
PLAN Coi4� K Ft, RE. 101.4100.4,19.31 S
CC+W.S.�'i'1"UC°p1Ut� F-PLE .1011-000.418-000 �Ib3.Q0
�ECHANICALF .-POOL, 101.090":4.2'1-000
a,
.ECTi2JCAle i EZ*'*aw 1�C7OL ' 101-000-420-000 $43.00
�'L,t1mpron. R tPOOL • 101 000.4.1.9-000 $27.00
'
} suB io vAL co1�i� rRuanow Am rTaw ��rRc:�
3393.36 .
LESS .PRM -PAID... � � z
'tai'.i�LTME1:Z74IDT )+�,.'�+'.8 DUEE NOW
JAN ®7 2004
f.
7
y
/
'I ®�•a •V.9YI16TA-Tr• may' 'f.•iifi , ,
FINANCE DERV
-
RECEIPT
DATE R ,
BY f
DATE FINALED
INSPEC
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
i
Underground Electric
/ZX
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
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
_
CITY OF LA. QUINTA SUB -CONTRACTOR LIST
/O`� -VI
'g ��N /V%�"PERMIT NUMBER
JOB ADDRESS��
•WNERMC� 1i' t-��✓ BUILDERA6_MBP,4A6_1 s�bo1S Fc�W JO-
This formshall be osted on the 'ob with the Buildin Inspection Card at all times in a cons icuous face. Only persons appearing on this list or their employees are authorized to work
01R this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to com I will result in a.sto
of buildin pP p y. ppage of work and/or the voidance
g permit. For each a licable trade, all information requested below must be completed by applicant. "Orr File" is not an acceptable response.
..... ,.,....��..., a...,.. ContractorState
Contractor' s License
License Number Exp. Date
lxxxxxxl (xz/xx/xx)
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F.
Workers Compensation
:.. ;...:.:.:.:.:;.::; :.:.:.:.:.:..:...:...:.
lnsi rance <.::....
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Citk Business
License
Company Name
Classification
(e.g. A, B, C-8)
Carrier Name
(e.g. State Fund; CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
_
EARTHWORK (C-12) ^- '� fi
S1N`1 " >%CIA,1 ,)
pct ��7—�/ '"1�
b o fl
-71
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CONCRETE /�
�(�
C
i �►
FRAMING (C-5)£'
L'
5 3 2000 i a7
1 9 4S�
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STRUCT. STEEL (C 51)
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Samir ru�v -
A 5Ls- 007-1/y 17e7
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MASONRY
MASONRY (C-29)
QbW
PLUMBING (C -36)
�.
bYo� a
. LATH, PLASTER (C-35)
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)
ty b
cP 00?L/q'7
o f o
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t
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING (C717)
INSULATION (C-2)
SEWAGE DISP. (C=42)
PAINTING (C=33)
CERAMIC TILE (C-54)
Cr1BINETS .(C-61
'FENCING (C=13)
'LANDSCAPING (C-27) .
POOL (C-53)
i
i
EMBRAND
POOLS & SPAS INC
CA. LIC. 800680 C-53
78-910 VIA VENTANA
TEL (760)'/CA-29P2P153 -21222153
FAX (760) 771-2181
POOL & SPA SPECS
POOL SIZE: 26'X 20'6"
POOL AREA: 316 SF
P L E 81 FT
POOL D P • 3' '
A SIZE: DIAMETER
SPA AREA: 50 SF
SPA PER: 25 FT
DECK AREA: 851 SF
STAMPED SAN DIEGO BUFF'
PUMPS: 2-2HP 1 HP.CIRC
FILTER: 400 SF
HEATER: 400 K
CONTROL: JANDY RS 8'
CHLOR: A UARITE SALT
CLEANER: NAVIGATOR
PEBBLE: DOLPHIN BLUE
WATERLINE: QUARTZITE
POOL LIGHT: 2-400 W
SPA LIGHT: 1400W
RBB: 12" RBB AS PER PLAN
MISC: 3- BARSTOOLS- 1- 30"
& 1-36" WIDE CASCADES
McLAUGHLIN RESIDENCE
ADDRESS: 78-910 VIA VENTANA.
CITY: LA OUINTA
0
DATE:
SCALE: 1 "=8'
DRAWN Y: DALLAS
JOB: