9801-157 (BLCK)t _ . t't.�• ;' LICENSED CONTRACTOR DECLARATION
0, �I,\l; her affirm under penalty of perjury that I am licensed under provisions of
F=' Chapter.9 (commencing with Section 7000) of Division 3 of•the,Business and,
cu�Frofessibnals Code, and'my License is in full force and effect.
License # Lic. Class Exp. Date
� fn
1 Lu
Z r- Date Signature of Contractor
0
cn 0.
J U C:) OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
( License Law for the following reason:
Z_ (,�() I, as owner of the property, or my employees with wages as their sole
eo?npensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044; Business & Professionals Code). i
( ) 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!&^ for this reason
N /Date _ ^-..Signature of Owner -7f",0 CJ
CL. Q WORKER'S.COMPEN_SAT,ION DECLARATION '
_`OQ I hereby affirm under penalty of perjury one of the follng declarations:
r � 0 O 1 have and will maintain a certificate of consent to self -insure for workers'
'.X WLL
compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q'U ) I have and will maintain workers' compensation insurance, as required by
Q'� Q . Section 3700 of the Labor Code, for the performance of the work for which this
.tl ;o H permit is issued. My workers' compensation insurance carrier & policy no. are:
0) Z Carrier Policy No.
J (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
3 subject to. the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with,thoseiprovisions.
bate:Applicant``
Warning: Failure_.to-secure Workers' Compensation coverageiis unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided foe in Section 3706
of the.Labor Code, interest and.afforney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
.application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the/above-mentioned property for.inspection purposes.
A !Signature (Owner/Agent) ' _ �. �. -� �' Date �'•
PERMIT# . —CONTROLq
BUILDING PERMIT
. �*11-15`7
DATE1 130/9 VALUATION '�`�P a. 5 LOT TRACT 6780
JOB SITE
ADDRESS
APN 7••'�•9g+i .
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1;31 50 AVENIDA 013KE&JIN
LA QU11 l'f'A. C:A 92""53
f 4iL.'f
USE OF PERMIT
BUILDING
6.5 L. F.. Y 43 ARD0,H WM.L. (13 T V S 6. AN -04113'.
S FT. VeAM. t33.tit) %i
VMVIIMA ti ED M- WT OF CONS Bow tCTIO
>3`Et$MtfT I FIE SUR f C Ry
` (".)14S't1kVr F1QN I�tDT, toIA1.1UC>-4[8-M)
PAI
JAN 3 0 19 (8
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SI,TR-'I' YYAI:, i.'ON.'3' I-.RtX T7t:1N AND PLAN r'_BEC K
$,13 no
I't3.9'a�.lt ii'E� i64S f Vfi?:PS IXIE stiff. W
$43.00
RECEIPT
DATE
By /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 APPROV L§
POOLS - SPAS
Steel
Set Backs Q
Electric Bond
Footings 101Main
Drain
Bond Beam //
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final S _ �r
PLUMBING APPROVALS
Gas Piping
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
l
Final
Utility Notice (Perm)
COMMENTS:
OWNER/ BUILDER INFORMATION
Dear Property Owner:
An application for, a building permit has been submuied in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as -Owner/Builder' you are the'resporisible 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 may protect yourself from possible
liabilityif that person applies.for the proper permit in his or, her name.
Contractors are required by lawpto 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 various trades'that you plan to subcontract, you should be
awar ,of the following information for your'benefit and protection:
If you employ or otherwise 7engage,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 anemployer,and you are subject
to several obligations including State and Federal income ' taz withholding. 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 these risks,are especially serious with
respect- to worker's compensation'insurance.
For more,specific information about your obligadons•under Federal Law; contact'the Internal.Re-ve.nue 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 BenehfcPayments and the Division ofIndustrial.Accidents:: `
If the structure is intended for sale, property owners who are, not, licensed 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 contractors is to secure an ''Owner /Builder" building
permit, erroneously. implying that the property owner'is providing his or, her own labor.;and 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 maybe obtained byco`ntacting the Contractors' State1icenselBoard in your
community ofat 1020.14.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';CalleTampico
La Quinta, CA 92253
(760) 777-7012 -
� FAX:
D
ER'S SIGNATURE/ ATE
PROPERTY ADDRESS
PERMIT NUMBER(s)