0008-415 (BLCK)LICENSED CONTRACTOR DECLARATION
*;'I hereb , affdrm under penalty of perjury that I am licensed under provisions of
h w Lha !."Sr 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O„co License # Lic. Class Exp. Date_.
CY lf)�.�
LLI � 7752 I A.�� �f •� ` �����
Z DateSi nature of Contraotor�
0 117
J U � OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ d License Law for the following reason:
Z_ ( ) 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).
C•`) () I am exempt under Section B&P.C. for this reason
LO
�! 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 )?XF.1e�F,1 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 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 3 .00 of the Labor
Code, I -shall forthwith comply with those provisions.,
Date:/ Applicanf'� +_„1� j+a ”
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
the above-mentioned property,for inspection purposes.
�}
Signature (Owner/Agent) Date
PERMIT# ". a..
BUILDING PERMIT
DAT._E�"�) ,P;VALUATION LOT '� TRACT
03W=
0 1
JOB SITE
APN
ADDRESS i2_61() AWM
WA O)3RP.'C O&d
- -
OWNER
CONTRACTOR/DESIGNER/ENGINEER :
4 RA�Mlf &.%LARON 131LU
IMACY HOIaRg
78.555 SAGUARO ROAD
78-555 SAGUARO ROAD
y LA QII.+1 A CA 92253
LA QUINTA CA 92253
060)564-7820 03110
USE OF PERMIT
0MIEM BURDINO
310 L.I:'. TH OAR DEN WALL, (RRTAININO WA1.L•f 01k91Af�'.�i�AU: ,
4 FT. WALL 210.00 LF
E5TBftTKD COST OF CONS•F. UC iON
3,3&11.00
PER QT M SURD" RY
CONSTRUCTJON FEE 101.000.418 000 $63.00
SUB -`DOTAL C.O23K.2UMON AIN PLAT C1lif t"K
$63,00
IMS PRE -PArD FEES
$0,00
7:'WAL I'LiMW1' FEES D0E
$63.00
w
RECEIPT,
1
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
OX 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
yPlumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
. Sewer Connection
Encapsulation
'Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
kFinal
Utility Notice (Perm)
OWNER/BUILDER. INFORMATION
Dear Property Owner:.,
t
An application for a building. permit ha's been sUbmiit,ed;,in yqur name listing yourself as the builder of the property
improvements specified.
1/,A3uild&%'.you] "h'sponsible
--re' ;:party of record on such a
For your protection you should be awarelhat as -Owner' areA e
esigne 'y- -'p' ty owners. un le'ss"t h ey are personally
permit. Building -permits to b- #b�,11 performing their
�
own work. If youiwork,is,beirig, peitfbime�d- �s citherit an yourself,you Protectlko urself from possible
i ". . '.1
. ,
liability if that person applies--forihe proper permi�i s�:r herna-
me
'l'eerfsed.ind1,8"ded`Sy the-gia'it of California a�'&td have a business license
Contractors are required by 1:iw�'t6 be 1 and .4
ey number AA permits for which they
from the Ciiy or County:,Th at
e a ,require., y. law to.put;t..eir , r
apply.
If you.plan to do your own work,"iiitfi the exceptionLol var.10"us trades ha
us tc kubcontract, you should be
aware of the followinginforrTfatio'n for your b6hifit and protection.
If you employ or otheiwisei engage any . persons otherAhan your immediate family, and the work (including materials
and other 'costs) is'$200.00.6r,*more ,,'for :the - e n't i t ieproject; ,and such -'Peirsoris are not licensed as contractors or
subcontractors, then'y6u may be inemployer.
If you are an employer, you. must -register with: the.Stateand Federal. d6`v6inrn'erft "as""an employer and.you are subject
IC,M,Pkpy
ral �social I
to several obligationvinclulding, State`and Federal, incomelix,:,withh6iclin"i es, worker's
-,security tax
compensation insura-n-'c't,,'di'sa6'i,li'tly�'insurance: costs and uAdifiplo'ytnent,compensa.tion-coh,fributions.
There may be financial risks ,for .you .,if you do not carry out these obligat ions,.,and thesi risks are especially serious with
respect to worker's compensation`insurance,
'For more specifii inf6irbatioriib'out,your"obligations under Federal Laiv,,'contkct,theJnteinaI evenue Service (and, if
.,-. "1 1- - - I . M- �,' , I - -1 .1 . Revenue
you wish, the U.S. SrAli B6ii ni"eii0A. dmi'n`§tr'a-'.tion).� Pior": more re s'p e. c i fi- c��'i fifor-ffia' tion':abo'ut. yourobligitions under Stave
Law, contact the Dipartirient'of Behefit'-Paymen-ts and the fDivisi-ofi'!of'I.nduitrial-Actide.nts.
'A,
If the structure is intended for sale,lo"propertyo'w�'neti,,wh6 -are not'_Iicerised-`c'ontrae4ors are allowed to perform their
work personally orifiriough t ei hour a licensed contractor of subcontractor, only under limited
conditions.
A frequent practice�of unlicensed per's;6ns--professihg,to.'be contractors is-.tto,,secure an ';Ow'ner/Bu'i-lder building
-N
perrnit,.erroneousli. imolying,.,ihat�.ihe,prbpe.rty'ownei:is':p,i6vi'diiig his;lor',her own1abbr',a4 matirleii own' worki.4, personally.
Building permits are not required 't&,1be*sijhed'by:p�rd
perty owner's , unless , they are p�terf6rtr ink their
personally.
Information about licensed 6dritractors,,may be obtained" by contacting.t Untr#tors"Staiteticense Board in your
community or at 1020N. Street, Sacramento', Ca,ljtoinia'_058514.
Please complete and ret6in'tfie enclosedowher-,,bUil4er'%ieiitication; form so 'liat. we. can confirm that you are aware of
these matters. The -building permit, will'nc�t be issued 'until th�e',Jv'eiifiic% _i'io'h'i` is returned.
Very truly yours,
CITY OF *-LA QUINTA
DEPT OF'.BUILDING-AND,SAFE',I'Y-;"'
78-495 Calle Tarnpido
U Quinta, CA 92253
(760) 777 12 . -
FAM(760)-77WOU-, Ir
NUMBER(s),
9,