0305-202 (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: .,
( ),,I, as owner of the property, or my employees with wages as their sole
adompensation, 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. fQ•'r this reason t
Date _ Signature of Owner All J.4 (! j
WORKER'S COMPENSATION DE KLARATION
I hereby affirm under penalty of perjury one of t)he 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.
(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 tXalf'not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree t� at if I rShould become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shatforthyv ith comply with those pr. tvision .
Date: r / . ,Applicant J- pv
Warning. Failure to secure Worker 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 authorizeAepresentativesfof this City to enter upon
the above-mentioned property for intpection purposes.
R r 11 44,
Signature (Owner/Agent), >94� J�[� i �� Date
t
BUILDING. PERMIT PERMIT#
DATE VALUATION LOT TRACT
$100.00
JOB SIE I——N
ADDRESS 52-1-455A�V. MAJ, �T'Bk!i}�+�.�7 OR
-
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
AR b U.E1, FZ
OVN t r5iffu- R
52•-155 AVDWA 0AR E0014
LA Qi'TMya, CA 1921213
(� a C Slit
USE OF PERMIT
P:1..1')NM.T G
70 LF OAS LINE FOR FUTURE APPROV XD (1AS ElHQ.
V.AI,UATIO14 100.0 I
ES'.U�l.'`IUTED OUST OF CON-VIRTJC'°l ON
1.00m,
PI�',1&nT FEE SU14AUAZY
-
PLUMBINO FFiR 101-000.419-000 318,00
MAY 2 2 2003
CITY 0yc L t1 K}LeYif gee
FIHA CE 4Ep",
SUR-170TAL COAI-9 -RUC-11 14 fiND PLAM CHECK
L..E M PR E -PAI d F?:'' S
TOTAL FKRMJT I@`M_KS .Di"1E NOW
RECEIPT
DATA / /�
BY `
DATE�?N D�
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
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:
OWNER/BUILDER INFORMATION
Dear Property Owner:.
An application for a building'permit has been submitted in your name, listing: yourself.as.the builder of the property
improvements specified. I,,
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 signed by property owners unless they are personally'performing their
own.work:.If your work is being performed by.someone other than yourself; you �rriay.protect yourself from possible
liability if that person applies for the proper permit in. his or her name.
Contractors are required by law to be licensed"and-onded by the ,bState of Californivand to have a business'license
from the City or'County.-They.are also required ,by law. to put their lice, nse' "num ber 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 in- come'iax wi&ol ling,' afederal `social `security taxes, worker's
compensation insurance,.disability;insurance,costs:and.'unemployment compensatiowcontributions.
There maybe financial risks for you.if you do not carryout these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
i.'
For more --specific information about your obligations undeff ederal Law, contact the Internal Revenue Service (and, if
you wish, the U.S., Small Business Adtninstiation).-For more specific' information about your obligations under State
Law, contact the Department of Benefit Payments and the, -Division of Industrial Accidents.
If the,structure i's,intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, withour'a'licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing lo, be contractors I.is to secure; an Owner/ Builder" building
permit, erroneously implying that .the. property owner isss- providing his'or her♦own Tabor and material personally.
Building permits'are not required to be signed by <property owners unless dey 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 form 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 922
(760777 012
F (76 )'7 -70
OW ER'S SIGNATUR ATE