0106-221 (RPL)LICENSED CONTRACTOR DECLARATION
1•herepy affirm under penalty of perjury that I am licensed under provisions of
C)napter 9 (commencing with Section 7000)-of-Dl'vision 3 of the Businne and
Professionals Code, and my License is iti full force and effect -__
License # Li lass-tt• -� 11'—�vJExp.� ate
Date,'/ r� Signature of Contractor
OWNER -BUILDER
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). l
O I am exemptiunde Section B&P.C. for this1reasoh
.� --•
i-..• ,
Date } �. ..Signature of Owner
rWORKER'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 issueif. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No. 20410-0019134
STATE ABID
(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, agree `hat if I should become
subject to the workers' co4ensationpro.visions.of Section 3700 of the Labor
Code, ;l shall fort with comply with those provisions.
Date: 1 P V") 1 Applicant—
Warning:
pplicantWarning: 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 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, anb State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inA purposes,__• t
S' nature (Owner/a erifj �� W Date !
t BUILDING PERMIT PERMIT#
DAT2 ' VALUATION LOT W06-221 TRACT
4q NN��
r{M�)�{{•��E
JOB SITE f
APN
ADDRESS
78-6110y' j @L jLR
OWNER
CONTRACTOR / DESIGNER / ENGINEER
HARJ ROX
TWaa, WMMM dlra VACA'r(ON POOLS
70 -:67th 11TAW.LES DR,
95 22 DONAI;I);'y N RD,
LA QM4 TA CA, 92253
LU(:it>RNE VALf,, Y CA 92356
('760) 249-6 45 MLO 4335
USE OF PERMIT
PCaQL MD/0"A MIA
P001, &_ SPA ONLY - PEWIT aMwd N0T INCLUDE BIA)CK •WALL.
ALAKMO MkIt a, St IWTKJ1 LHD MOR TO PRIK.- r' AISTEf. I'148MMON,.
POOLANNORSPA is
XS71MATKD C091* OF COMPTNUCTION
11500.00
T�I�"t<?8�111iC1A !�K:F !�1.•t3Ufy�i3!J�31.8
101.,000-418-0f}t? 6o�.lii+
MPMANICAL PEL'O -- N001, 401-000-421-000 %24,00
eLECT :1CAY F1119_Pool, 101-000-420-000 $45,00
1'I,UMBINO Va -- Pool" 10
I
MAY i
2 5 2001
Ci TY OF LA OUIN:TA
"NANCE DEP:i
��l•: H—To C�4'L CO�i�I(�t,11c�1a A`�y•a Pp ,ff��yyff
;�36�ina,30
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1.. EUS P.i1. 1-I MID X'.L: UCT
" $0100
IAIALTIMAIIT 101M DIVE' NOW
$304-10
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
19)y�.
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
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
!,p/���
—�
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)