9908-096 (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 fforce.and effect.
License # Lia Class Exp. Date F f
/61 1892 C i3A a
ateS ignature of Contractor 4)
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 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.
r.r Ia
t�n.^t.� +va. �a� iifitiL�.iNfv{)kii{
(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 shal,�ot employ any person in any manner so as to become subject to the
wor ers' compensation` laws of>California, and agree that if I should become
suject to the workers' compensation pr6visions of Sectio 3700!of they Labor
Code, I shall forthwith comply with those provisions. ' ,✓�
VDate: r i- I QApplicant f! �
> t .
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 o,n 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, 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 comply4ith all City, and State,'Iawssrelating to the building
consipction, and hereby?authorizer represen�atiCes:of t `issjcity to enter upon
thZature
above-mentioned property for inspectionpurposes
If
(Owner/Agent) '41 Date
BUILDING PERMIT PERMITk
DATE VALUATION x'rLOT TRACTJOB SITE
..
ADDRESS 80.045 VISTA. �ri 1.4NDE APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
40015 VISTA, ORANDE 23► -5 S. VINEYARD AVENUE, SUTE A.
I..r"1.QlJt{vTA CA. °l2a2'r10 t?NTAWO CIA 91,761
0.9(Y�)9474074 CAU S240
USE OF PERMIT
k'i:lrs.;+l. & ,PA.ONLY - Ag..tit.ItW� 1M,' i :tEkS �j hit A.. tilt Im sPI.tb.C6 A, -'I
3'i �•l�l.,s'1:si t. INSti V."rlO`N
MiYl , Aati7 P °E VA
18,(it.+U.00 1.3
9�4,!1IN +',",:E•iisC K 3r`EW 3 01-i3!,.t`t!-439-3 i 9
l�i�'l�.i-.{.r�i4'tii�)�if. ��{" •.���K,{.. �i��-("r���^QrQ�� �.u'{:
rdJA; `l;.UCALI t.H• _-P;s0I Wt 00042iMCi+3
PLILINJIMN0FEE - POOL IOI..M-40-000
K
E1T�wT{'3s'i�(!,C'C)�f�iF?..tiC,'i°t��i!3 �.4I�"�?3rR(Npr•�tl�ty"�t �
TO 11 V14 0141M.M1
"XMIT Fol
RECEIPT DATE BYAJ Y DATE FINALED I INSPECTOR
131,1 t1>0.310
5407,ft�
1�O 100
07.95
;.•,,rfv
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
tax
Set Backs
Footings
Electric Bond
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
—
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:
GENERAL POOL SPECIFICATIONS:
smp. # �
Z 1
APPA-_41al
EXCAVATION
DECKING 4
.Access Front ear
Type GQN_CRO
T�
Bob Cat - Shuttle Dig
Color
!
Remove Dirt
Risers
1
Remove Stump(s)
Footings
Remove Fence
Mastic
I
Replace Fence
Drains
Remove Concrete S.F.
GX O r NTS
Sawcut Concrete Ft.
EQUIPMENT
.
Filter T e AZT Si
����--•��
' {�C�
STEEL
Pum HP Z r
S
1 S I
Expansive Soil Steel Pattern BH
B.H.C.C.
es
No
Ozone
Yes
No `
PLUMBINGP/P+/Or
Zfl r
SmartLiaht
Yes'
o
Filter Run Ftg:
Return Lines
500 W Light
s
No
P -Trap B/Wash Liner
SmartVac II
es
No
Gas Line If' Ftg .GO
Ir
Heater BTU
at
Pro
Drill Drive
Div. Board
ELECTRICAL
Run By B/k Ftg
Slide
Water Feature:
0
1
GUNITE
ove Seat
PLASTER'
I
Swim Out
Color
I
Ext. 2nd Step
R.B.B. in. X - Ft.
SPA '
7
I
_
Size
In
Out
R.B.B. in. X Ft.
Plumbing Run
'_ .� • Approve equipment location _
Understand that decking shown is for illustration purposes only and -
understand that they are to receive square feet of deck.
- Signature Date
L•'
Prepared to or.
P epa Especially F
4
_ ;i:- --- t V lST GRAry
�' Flo." sPA... `� � .• _... --- � _. E�/Et.rrl GAI�cwG
w� t-_ r TE
Street g0 -645I l STA .GRAr`1(J�
I - city L. A g01A-T I a Zip gz2.S3
_ Home Phane 34-7 - 77t� Work Phone
sIor woue- WILL BE CHARGED.IF THE }APPROVED
w.�
PLANS AND JOBCARDARE NOT ON. Designer .lob No.
THE SITE FOR A SCHEDULED_ g
l I Lot �� Block-" Tract
INSPECTION.
.NO EXCEPTIONS! Mapsco No. 6 ` � 42 -CO Z - Z