0009-002 (PAT)LICENSED CONTRACTOR DECLARATION
:C' JJ ereby 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 exerppt,under Section B&P.nor this reds n+
Date a 14 Signature of Owner17)
WORKER'S COMPENSATION ECLARATIO
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 ;Athe_!.wo.rkers' compensa)jN provisions of�Section 3700 of the Labor
Code, Irt"with comply witt those p OVISIOAlQ.
Date: – Applicant-
Warning:
pplicant Warning: Failure to secure Wor ers CompeLn'sat& 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 prope orinspect; n purposes.
Signature (Owner/Agent) Date—5 S �/
BUILDING PERMIT PERMIT
DATE,.- r VALUATION LOT �'� TRACT
JOB SITE
APN
ADDRESS 53-020 OB VEGON
-
.AlVEMA
t
OWNER
CONTRACTOR / DESIGNER / ENGINEER
J1114;RR Y' JAMSON
OWAiWf3IU DER
53-020 AV0.4DA OBREEGON
LA QUWTA CA 92253
CBLO
'
USE OF PERMIT
PAnOi
120 L.I . LATTICE PATIO COVER - PER APPROVED PLANS ONLY ,
POPIMPA1110 110.00 SP
t
ESM"ITM COST OF CORY]I IiUC'1r'tOR
1�,�45.0tP
PKRZA ' FIM 3uMb"Ry
PLAN CHECK FEE 101-000.439.318 $24.05
CONSTRUCTION PE 101 _000418-000 $37.00
'
Si1t02IC3 tJiO'i1OW ixtr: RAID 141--241.400 1.50
s
e.� e
�c
r%
90IB-T(Yx AL COr1STRUCUGH AtM ]YUX9 (--ffiM.
$61.51
LESS PRE -;PAM FM
$0.00
TOTAL I'ERAUT MSICUE
$61. r'
_ /�„ Yom-
LA� 1
i
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
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 I I
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 'INFOkMATION,
Dear Property Owner:
An application for a.bwilding permit has been submitted in y'o'ur name listing yourself as'.the builder of the property
improvements specified:
For your protection you should be aware that,as "Owner/ Builder" you are theiresponsilile`party of record on such a
permit. Building permits are not'requiied tobe.signed by property owners unless: they are personally performing their
own work. If your work 'is `being: perform ed by someone other:than yourself you may,. protect yourself from possible
liability if that person"appl es`for the propee-peimit in. his ouher
Contractors are required: by law to be licensed•'and.bonded b , he5tate of'Californtaand`to-have a business license
from the City or County. They are also required'by law io: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 i6 -subcontract, you should be
aware of the following information for your;benefit.and'prote'ction
If you employ or otherwise engage any persons other than your.immediate farriily and the woik�(including materials
and other costs) is $200.00v,;,6r :more: for 'the entire .project, and' sucl .'persons are nor licensed as contractors or
subcontractors, then you
maybe an employer.
If you are, an employer, you.must register with 'the; -State and Federal Government as an eiriployer'and you are subject,
to several obligations including State and Federal income, tax ;withholding federal-soaal 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'obligauons' and these risks are; especially serious with
respect to worker's compensation insurance.
For more specific informationabout your obligations underFedeial Law, contact theelnteinal'R'e'venue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific,information about'yourobligations under State
Law, contact the Department of'Beneftt Payments and the Divisio ii,bf-Indu�siriA.Acciclents.
If the structure is intended' forsale, property owners vvl%o are. not licensed contractots:are ,allowed to perform their
work personally or- through :their own employee's, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of.unlicensed persons professing to,be contractors is to'securii an".-Owner/Builder" building
permit, erroneously implying that. the prop erty',owner' is. 'provi`ding,his or her' own' l ; nand 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 retuin the'enclosed owner-builder.verification form so=that we can confirm that you are aware of
these matters. The buildingper'rriit will not be issued` ritil th" verification isreiurned.
Vcry truly yours,