0210-163 (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
: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
,D&te 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 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 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I .agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection -purposes.
Signature (Owner/Agent)-`--,-.;w�' ' 'Date
:r. tiw
K.+' r PERMIT #
PERMIT'
►.�ID'1NG
�n�•.
DATE��+�; VALUATION" LOT TRACT
JOB SITE
ADDRESS 52..77() AV.ice.$ A 013 (3-0I4
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MW.IDT C.`"IF1% 1''3 ,
O'{IJ'f4'F.k - BUILDER.
TY.O. BOX 386
PALM, D.ESi:Iff CA2,,261
USE OF PERMIT
P Ui MMI
SEPTYC: A.I 1.1140 lNbt EWT; 51.'VF_X 4. 0Oti -UP
-
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Vr3t.4llti`i1fN 1,700.00 W O(,,
C of
UAQUINTA
P1 ANCEDEPT _..._.._..
5
Q
MMA g M C oUr OF CO.i fffg w"I.7'on
1.700.tw
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P1s PI MAIL'��'1 `EE
r rt�i^T-1�,��4as� CRY tN af� hfy
i�7aT.:}&1OTY40 FEE — SEWER 4101 -WO -439-000 4.70,00
81M-T('YTA1., C{J13TIMRITC,°MM Aid.} IPI AM CMCK
$10,00
10193 F,P.%••3'AZI,?.'C+ista:�.^1
w0.00
TOTAL Y'ry"I ' TIMS ].1[?.f+r NOW
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
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_
Pool Cover
-
Sewer Connection LU y 2
Encapsulation
Gas Piping
Gas Test
Appliances
'ejZ
d'
Final
COMMENTS:
/�GT
Y
`
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)
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OWNER/ BUILDER:. INFORMATION
Dear Property Owner:
An applicationfor a buildin' peimit,has been submitted in yourself I
9 your name, li irig you I -i� builder of the property
improvements specified..
For your protection you should be aware thatas -Owner/ Builder".ybu are':the,respohsjbleparty of record on such a
permit. Buildirig,permits are not required to be signed by property roperty unless they are.peisonally peifcirrning�their
Building
.permits
work. If yourworkis being performed by someone' otherthan yourself,';you may protect t yourself from possible
P
liability if that person applies for the. pf o*per permit in his or'her. name.
Contractors are required by law to be licensed arid bonde&by.th&S6aiie:of Cadif6inia"afid to have a business license
from the City or County. They are also required by law* to put theirlicense, number on all permits for which they
apply.
If you plan to do your own,work, with the exception ofvarious ,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 ypur,,irnmic.dlit,e,farriily,;,and,the-work.,(includin'g materials
and other costs) is $200.00 or ,more for the entire project;
t; and, such,-pers'ons, are 'not icensed 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 -severaFobligations. including -State and Federal .i-nc6m&,-t'ax-wi'tiii�oldini,—federa'il=soc'ia'l-/,secu'rity- taxes, worker's
c0impensition.insura"nce', disability insurance costs and'uhemployment comp I ensation contributions.
i '
There may. be financial risks for you if you do not carry out these obligations, and these r sks" 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 Bb'siness Adminstrition). For more specific -information abbuit"your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property. owners wh6are not lic'ens4c'ont'ractors are',allowed to perform their
work personally or through their own employees,,.without a license&6'ririactor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed ,persons -professing to be,co.ntractofs:-is to*secure.an.',',Owner /Builder" building
permit, erroneously implyin&,that the property owner is pioviding 'his or her own laborand material
personally.
Building permits are not required, to be signed. -by property owners unless the'y.are"'p0orming their own work
personally.
Information about licensed contract , ors may be obtained by contacting -the Contractors' State License Board in your
community or at 1020 N. Sacramento,Street';''California 95814.
Please complete and return the enclosed owner -builder verification,f6im'-so, that we can to'nfirm that you are aware of
these Matters. The building peimit*ill' 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
FAX: (760) 777-A
OWNER'S SIGNATURE/ DATE
PROPERTY ADDRESS
Qr2 /o n &3
PERMIT NUMBER(s)