0311-068 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that-] 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 7
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. f& thd reason
Date Signature of Owner T` Pt-�
/
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.
�(>4 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 f orthwith comply with -those provisions /,—y
Date: /I (�',) Applicant /(",I. I
Warning: Failure to secure Workers' Com pensation`bbverage 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, indemnity
& 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 in'sppe tion purposes.
Signature (Owner/Agent) !' Date
' E
6UILDIN — PERMIT PRMIT#
eMIT t g�
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS a',1-9,AVEJ.91 .DL'A OFIRIE OR
APN
- -•
OWNER
CONTRACTOR / DESIGNER / EN INEER
$MT) H.OF b!tAltiO
Si�IL�i7ZY7n
52-952 .AVENMA OBILGON
LA QUiN%A CA 91253
USE OF PERMIT
C�F.,NAY. BFTU..83I221'�3
981. F 6` HLOCK WAf.I.A112 LF Y BLOCK WALL PER CITY STANDARD
d rf: WAJ L 43M Lr
3 F7. WALL 113.00 LF
=SrV4A7CKD COST OF COAV;S`M'C CCMOA
?MM FKE 6UfAAM 1k
CONSTRUCTION FEE 101.000.41&.000 t 11,tl0 '
Q p
p
NOV 0 7 2003
CITY OF LA QUINTA
FINANCE DEPT.
SUB..1 fAl. CONSTRUCT101T 1'M PLAN UIECK
V12.00
'MTA11 PEIMW OWES DUE. NOW
.s
RECEIPT
DATE -)•7
BY�
DAT AL
INSPECTOB.
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 I
I I
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
- o Z7 OW
Approval to Cover
lr�e_
Equipment Location
Underground Electric
Underground Pibg. 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 -
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
Final
Utility Notice (Perm)
Site Requirements for:
.`Fencing .' fttnibn "s
REAR and -EXTE-RiOR.SIDE YARDS-.
mu"st.be'cofnpI,e'teI losed and scfeefied......
.-by a Five "(5j Foot; High
C.
View-obilcuriftg,fefice -or will.
CHAIN-LINK FENCINGti
IS -PRO 1BITED.-
C
fd
g
`
Minimum' Requi�re
ehci
F Icin'
be a.,
F ces.,,, Is'., an
mAxiin.iim:,offive (5). feet,jhigh
..An,: - the Fidht1.and St e' y
et"Side 'ards,
Six ,i'(6)',.feet- high; in the Rear and
ihi"e"n*or,�Si"deyardifid.,30 inches
in - the - Co m-er -_Cut-back. area on
comer Lots..
Alf fences..and-*walls M0'be
�,ntahritafned-in g' 9' gid repair:
F LA QUINTA
CITY
Fq!
BUILDING,& SAFETY DEPT.
Corner tut*b'ick Area
APPROVED
FOR CONSTRUCTION
8
DATE BY -
0
OWNER/:BUILDER INFORMATION
Dear Property Owner:
An application fora building permit has been submitted .in youi'name,'listing.yourself as the builder of the property
improvements specified.
For your protection you should -be aware ihat-as "Owner(•Builder' youare the responsible party of record on such a
permit. Building permits are, not required to be.signed by properiy'owners unless, theyaie personally performing their
own work. If your work is betng,"performed. by.so'meone'othe 'than yourself, :you may: protect yourselffrom possible
liability if that person applies for the proper permit in his or -her name.
Contractors are required by law 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 variuus�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 tmmediate family, and the;work.(including materials
and other costs) is $200:00 or'more for the entire project, and such`persons''are., not aicensed as contractors or
subcontractors, then you maybe an employer.
If you are an employer, .you must register with the State and Fedeial Government as ane loyer and you are subject
to several obligations including State and Federal income tax w.Ah"olding; 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:t�hese,risks are especially serious with
respect to worker's compensation'insurance.
For mores specific information about uf.your, obligations under Federal Lai+;:contact the.Internal Revenue Service (and, if
you wish, the U.S. Small. Business'Adminstration):`;For more specific information about; your obligations under State
Law, contact the Department of Benefit Payment's and'the Division of Industrial Accidents;!
If the structure is intended for sale, property owners who. are not luensed 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 unlicensed persons professing to,be contracionji to secure an "Owner /Builder" building
permit, erroneously implying that- the property owner is providing his of her own laboi and 'material personally.
Building permits are not required to be signed by property, owners unless t}iey ate peif, ing their own work
personally.
Information about licensedcontractors maybe obtained bycontactrig;;the Contractors' State License Board in your
community or at 1020 N. Street; Sacramento; Californta.938,14.
Please complete and return the enclosed'owner-builder-verification.f6rmso that we -can confirm that you are aware of
these matters. The building permit will not be issueduntil 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: 0) 777-70 1
OWNE SIGN /DATE
SZo�Z�1
PROPERTY ADDRESS
PERMIT NUMBER(s)
A