9906-039 (BLCK)�• LICENSED CONTRACTOR DECLARATION
(,.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
Profed'sionals Code, and my License is in full force and effect.
Licen e # _ 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:
() I, as. owner of the property, or my employees with wages as their sole
,cNrIpensation, 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)
( ) Jram exempt under Section B&P.C. for this reason
ate%Signature of Owner , �a '� L
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.
M T IRINSIlIt NCE, r: Pit 3:1.26 71
(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, and agree that if I should become
subject,tb the workers' compensation provisions of Section 3700 of the Labor
Code I shall forthwith comply with those provisions. 1
�te: ., Applicant X
' ► .,
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 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
thea • ove-mentioned property for inspection purposes.
ySignature (Owner/Agent) � ._ � : •-a Y . r^ l a f . = `� Date fF+' :+
BUILDING- PERMIT PERMTN
n.
DATE (%,107f.194)VALUATION $1,000.00 LOT TRACT
JOB SITE
ADDRESS rc� S`Ci?1 . �k
APN 773-714-012
OWNER
CONTRACTOR / DESIGNER / ENGINEER
AURELLA. WICK$
0W`NI R / RUIL DER
52013 AVENIDA OBREOON
WI'T'H WORKERS COMP INSURANCE
LA QUINTA CA 92253
USE OF PERMIT
e jRN' ;R.AL BUILDING
40 L3., e' GARGIL'ly WALL (SFE ATTACH D e�N0fhiaR Q ) WITH
PLASTER FINISH
6 FT. WALL 40.00 LF
Itd'I3'r tIl AT.ED CMT OF CONS'rRUCTIGN
3.000.:$(8
1TR.MIT FEE SI MAIARV
C01g9,rR.UC"i K)]N FEE 101-000-418.000
5trfd-1'OTAI.CONNT.N.[_r(;"110-NIAND PJl ANJ1:'iIP,(:X
$25,W)
I.ESS PRE -PAID PEFE''S
$0,00
"I'OTAI, J'!h;RMI'.If I<i'EMS I UE"INOW
$25.8>Iti'
i
RECEIPT
DATE
By,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
J `
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 8 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
I- I z- 00 S T
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
I_.;kS_C2b15. t
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:
a INTERINSURANCE EXCHANGE of. the Automobile CIUb1.
PROPERTY..INSURANCE,. RENEWAL.DECL`ARATIONS
;
• MEMBER'S DELUXE HOMEOWNEFt POLICY—.FORM 3 . .
PLEASE READ: These declarations constitute"our offer to renew this insurance for1he;policy period shown below. Renewal is contingent upon
your payment of at least the Minimum Due before. or on the Due Date shown.in the enclosed Insurance Billing:.Failure to pay at least the Minimum
Due before or on the Due Date shall mean that you rejected this renewal offer -All coverage affo4ed.by this policy will then terminate at 12:61
a.m., Pacific Standard Time, on the Effective Date shown An I ese' declarations under :'Policy Period." These declarations,"together with the
contract and the endorsements in effect, complete your;policy.. s.
ITEM 1. YOUR NAME AND ADDRESS �' ID .POLICY NUMBER
y•
.3-29 99 PH 3326571
a H26 i
WICK, AURELIA POLICY PERIOD
52015 AVENIDA OBREGON 4(PACIFIC STANDARD TIME)
LA QUINTA ,CA 92253-3238 'EFFECTIVE DATE 5-27-99 12:01 A.M.
EXPIRATION DATE 5-27-00 12:01 A.M.
ITEM 2. LOCATION OF PROPERTY (IF OTHER THAN ABOVE) THIS POLICY DOES NOT INCLUDE BUILDING
: CODE UPGRADE COVERAGE.
ITEM 3. COVERAGES AND LIMITS OF LIABILITY ' COVERAGES'ARE Sl1BJECT'TO ALL CONDITIONS OF THIS POLICY.
PART I—P..ROPERTY COVERAGES
�
:'PART -11 LIABILITY
COVERAGES
PART IU—WORKERS' COMPENSATION
'A B
C
"
AND EMPLOYERS' LIABILITY COVERAGES
DWELLING OTHERUNSCHEDULED
D ..
E
F G
STRUCTURES
PERSONAL ,
'PROPERTY
'{,PERSONALVLIABILITY
!' MEDICAL PAYMENTS
WORKERS' EMPLOYERS'
$139,000. $13,900
' $97,300 4
BODiLYiNJURYAND PROPERTY
DAMaGE-EACH OCCURRENCE
PERSONAL INJURY—AGGREGATEr
TO OTHERS—
EACH PERSON.
•'
COMPENSATION LIABILITY
GUARANTEED REPLACEMENT
COST INCLUDED
.
b'..
$300,000
$5,000 ..
PER POLICY $I00,000
DEDUCTIBLE $1,000
RESIDENCE EMPLOYEES
OUTSERVANT(S) 0 INSERV4NT(S) 0
IN ACCORDANCE WITH THE E.H. BOECKH COMPANY
INDEX, PART I LIMITS WERE ADJUSTED BY02.6 `b
ITEM 4, ENDORSEMENTS
NUMBER
TITLE +
PREMIUM
H0=184
VALUE GUARD. .
H0-216
ALARM OR FIRE PROTECTIION SYSTEM
HO -290
•PERSONAL PROP ERTYREP,LACEMENT.,COST;'
$ 33
438BFU
LENDER'S-LOSS'`PAYABLE.ENDIORSEMENT"
THI,SJ)bLICY;DOES NOT PROVIDE COVERAGE
- AGAINST -THE PERIL'•OFaEARTHO'AKE
ITEM 5. PREMIUM DISCOUNTS
MULTI POLICY,
NEW HOME
FIRE -RESISTIVE ROOF
FIRE ALARM
BURGLAR ALARM
DEADBOLT
NOT
YES
YES I
NO
I YES
ITEM 6.
BASIC
LESS
A D,D I T 10 N A C C O V E R A GGE S
CIGA
NET TOTAL
COVERAGES
DISCOUNTS
INCREASED _ INCREASED RESIDENCE ENDORSE-
ASSESSMENT
PREMIUM
PREMIUMS
PERSONAL . MEDICAL - EMPLOYEES MENTS
LIABILITY. PAYMENTS'
.x$428,
$94,
a
$16 $9. $33
$394
ANY LOSS UNDER PARTJ=OROPE_ RTY COVERAGES—IS PAYABLE AS'INTEREST MAY APPEAR TO YOU AND
MORTGAGEEYI LOAN.:# 66439426
BANK'OF AMERICA,.FSB ~2
ITS SUCCESSORS AND/OR ASSIGNS
BARELA INSURANCE, DEPT 24134
P 0 BOX 57060
IRVINE CA .92619
HMR0040A FOR QUESTIONS OR CHANGES CALL TOLLFREE- 1-800-924-6141
EOasa SEE REVERSE. FOR PRIVACY PROTECTION NOTICE
OWNER/ BUILDER INFORMATION
Dear Property Owner:
An application fora building permit has been submitted in your namelisting "yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/.Builder'' you are the responsible party of record on such a
permit. Building permits are not required to be signe&by property'owners unless they are personally performing their
own work: If your work is being performed by,someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit to his or her name.
Contractors.are required byelaw to be licensed'and bonded by. the State of California and to have a business license
from the City, or County. They are also required .by; law to put°their license. number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you, plan to subcontract, you should be
aware of the following,'information for your benefit and protection:
If you employ or otherwise engage any persons other, than your immediate family, and the work (including materials
and other costs) ,is ,$200.00 or more -for the entire, project, and- such persons are not licensed as contractors or
subcontractors, then you may be an.employer.
If you are an employer, you must register with the State and Federal Government as an employer -and you are subject
to several- obligations- including State and' Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability, insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under.Federal Law,.contact the.Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration)..Formore specific in for mation'about your obligations under Stare
Law, contact the Department of Benefit Payments and the. Division of Industrial Accidents.
Ifthe'structure is intended for sale, property owners -who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor, or subcontractor, only under limited
conditions.
A frequent practice of un licensed•persons professing: to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing, his or her own labor and material personally.
Building permits are not required to be signed -by property owners unless they 'are performing their own work
personally.
Information about licensed'contractors may be obtained by contacting the. Contractors' State License Board in your
community or at 1020 N: Street, Sacramento, California 95814.
Please complete and return the enclosed owner-builder`verification forri so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA "
DEPT.- OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760)777-7012
F 760)777-ZO11
OWNER'S SIGNATURE/ DATE
PROPERTY ADDRESS