0309-193 (PLBG)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 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:
(kk) 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 G" 6 � 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 37bo''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).
(°S)k.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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, 1 shall forthwith comply with those provisions. ;-
Date: 3 " 1 d t Applicant '
Warning: Failure to secure Workers'' Compensation coverage1s unlawful and
shall subject an employer to criminaj 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, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) f'y . - Date ' i
I
,
BUILDING PERMIT , ,.- PERM``#
DATE VALUATION LOT TRACT
9/1
JOB SITE
APN
ADDRESS
5 p
OWNER
CONTRACTOR / DESIGNER / EN &NEER
T0,UQap:VIZ
iluTU ;R
:+f -x 1 VENMA •;?M7,0CIN
1.11 Q�il 'i' - , CA. 91253
( OUR
USE OF PERMIT
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CITY OF
LA QUINTA
FIN NICE DEPT
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�Cts�`°t>i:�X•C_10 _!n., IT117TIONAMD PLAN ffW_'1 X.�3f).RC1
1.111KII FRE-.PAU F%NJRM
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
emp. Power Pole
-Underground Conduit
Rough Wiring
Low Nottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
S _ U
_40 4:"?M,,,
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL N9 96595
Received From: (�'� C`� 7 ` !
Address: } / g �.:.0 �� Date -
Account
- ,�G� t�_
Account No. CD/ Hii (cGJ C f l
Lot(s)
Service Address �� - G /) �i'Ge;• Tract ;
'O Meter(s) G.A. Code
• I
'❑ Service(s) A
$ `
❑ Backflow(s) i
❑ House Lateral(s)
❑: Detector Check( s)
' 0Meter Surcharge
..q" SanJ?,ati.n Capacity Charge,
0 W.S B.F.C.. , S
❑ Temporary Construction Meter
El Turn on Charge
7 Uncollected Account - Name '•
J Inspection Fee - Tract -
Fee -
f ] Plan Check Fees Water Sewer -
Tract -
-------------
] Bond Payment - A.D. - Bond
Assmt. f
I - Customer Deposit
Other
f i_ / TOTAL
Remarks: IP'lk 1(7'01CI �/p iJ
C
ash
heck Water Service i
der M y 3
Cashier
• t
OWNER [BUILDER -7 INFORMATION
Dear Property Owner:
A
An application for a building permit has beenrn
submitted in your isting yourself as the builder of the property
improvements I s I pecified.
For your protection you should be aware that th(:fes tinsible party of record on such a
4� Irq unless �'ez' are e" 'piersonally performing the'
permit.,Buildir;16ermits are not fe`quiredio-be signed by,property owners Ln I it
,��L
own work. your work is'bein'g'�perforffied her than yourselfY'OU_'� may protect yourself from possible
liability if that peisonapplies ,for the prope
r',o e i in i in his'% r, h e r nam -C..
' ' 'Fby the State California�nii and to have:a business license
Contractors are required bylaw to be lictnse .d
and' ondec
from the City or'County. They,ar'e`,,algo required by�)"V- to , -p . ut.tEeir,license,,num6eion,alI permits for which they
apply.
If you plan to do ydur owfiwork, with the exceptiori,6f 4rious'liracles-lhit.yc�u plan to subcontract, you should be
I . '
aware of the following infornWtion.for.
Your benefit an protection:S.Y
If you employ or otherwise engengageany,persons other ,ihaii-�6urimmediate and the work (including materials
and other costs) is $200:00 or,mcre for the entire project, ,rand s&-h,,y"es6ns1 are` not licensed as contractors or
.,
subcontractors, the'ny-ou may lie an emp oyer
A
If you are an'employer,,you must regisi'er with, the'Sta't'e',"a'n'idFederal Government as an
11
,!mP1 e
r,and.you are subject
to several obligations including State and Fed�ral iGx�withholding federal 16 iaIsecurity taxes,
worker's
compensation insurance; di:s7abilit y'insurame costnad �7hejl6y
mcompensation contributions.
There. may. be financial ancial risks for you ifybu,clo,not carry out these oblijati6ns,,ancl,these risks are especilally serious with
respect to worker's compensation insurance. -
For more -specific, information about yout,6blig;tionsJ:iifdEr FedeialLa-,V'co'�ntac;t'the Ihternal Revenue Service (and, if
M�i I, .. I 1� .1 I < , ,
you wish, the U.S -Small 13usiness.Aaminst:iiti6�').:For '-more 's�.ecifi'c"in . matiomabout,your obligations under State
Law, contact the Deparitiment of Benefit;P*a"y'ment's and 't"he':biv'is'i'o'n�6tI'�8'ustrialAc*c'id-en ts.
X �0.31,v
If the structure is intend Af6r sale, property owners who are nor Lcensea contractors ire'allowed to perform their
work personally or through their own emp16yeei, withpilt'a licensedcontractor :bi subcontractor, only,uinder limited
.
conditions.
Afrequent practice of unlicensed persons professing to be contractors is to secure�;an',"Own'ef/B,uil.der" building
perinit,'erroneously,'im
plying, that the owner is.provicling his i-60her -'owfi -labor and material personally.
d y� 'e, work
Building permits'are;aot require to be,sign1!e
by owhers'.un unless they ii performing their own
personally.
Information about'licensed. . co . n tractori'may 1;e. qbtaified by contictih&ihe Coritracitors� State License Board in your
community or at 1020N. S.treet,*Sacrainento,.Cilifornia958i4.,
Please complete and reiu'rn, the enclosed,'Ownii-�.6.uilddi..V'e'rifi'cation..'fbrrh to thaqwe.canconfirm that you are aware of
these matters: tKebuilding permit will not be issueduntil:'the verification is returned`
ned:
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING % AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012
(760) 777-7011
•ER'S:SIGNATURE/DAT I
S/ -asp
U
PROPERTY ADDRESS.
4*
PERMIT NUMBER(s)
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