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0310-070 (BLCK)LICENSED CONTRACTOR DECLARATION 1 -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: (y), 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°e,. contractors to construct the project (Sec. 7044, Business & Professionals Code). () I am exempt under Section B&P.C. for this reason" ✓bate Signature of Owner.. r'r'i7f 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: Cartier Policy No. (This section need not be completed if the permit valuation is for $100.00 or less). (�t) 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. 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) ! ~__ Date BUILDINGRERMIT' PERMIT# ' 7'��-� r✓ r DATE y g�� VALUATION UrT ' TRACT JOB SITE APN ADDRESS &3�41 15 A VWIDA. 0BREGC3N - ^ OWNER CONTRACTOR / DESIGNER / EN (NEER ' DF 5.3-415 AMMA, 0DRECKiN LA, QU.DJ Tao CA 9M 3 � } • t'BI.s� USE OF PERMIT GI RAL BIMMNO 501,F' 6" 11•LOC'K WALL PER CITY ST4040AW R.E. AR PBL d'", WALL l.,>± COST OF CONSTRUMOK CONSTRt�tY'9��oAT l i a4o0n41 Rmudtl VIM OUT 07 2003 t CITY OF LA QUINTA FINANCE DEPT. r SUB -TOTAL CCiNM CTC' 1 0kl AND PLAN CURCK $31.00 LEE PM:-PAMI FEF3 $01010 MT6AL .PET4Mn'FFEh4 DUK XE?•W 1.00 RECEIPT DATE BY DAT FINALED TINSPECTQP '�f9. 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 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, INFORMATION Dear Property Owner: An application for a building permit has been submitted.in your name listing yourself as the builder of the property improvements specified. For your protection you should -be aware that as''Owner/u Bilder" you are the,responsible party of record on such a permit. Building'permits are nourequire'd 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 liability if that person applies for the proper permit in�tiis or her name. Contractors are required by law to be licensed an`dbonded by, the State of California and to have a business license from the City or County. They are also. required`bylaw'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 aware of the following information for'your benefit and protection: If you employ or, otherwise engage any person other tha .i 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'Fedeial'Governmentas,an employer and you are subject. to several obligations including State and Federal'.income -tax 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`coinpensation insurance. For more'specific information about your obligations under, Federal Law, contaci,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 Payments and the Division.of Industrial 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 contractots;is-to secure `an "Owner /Builder" building permit, erroneously implying that .the property owner `is providing his, or her own'labbr. "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 may be obtained by.contac"tin_ g the Contractors' State License Board in your community or at 1020 N. 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'ihe verification" is returned. Very truly yours, CITY OF ILA QUINTA DEPT. OF' BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760)777-7012 FAX: (760) 777-7011 OWNER'S SIGNATURE/DATE s3 5'/.� /�✓c��lee �,6�-cc�m, ,<� /? 2z) i� 9C�ff,.3 PROPERTY ADDRESS - PERMIT Ni1MBER(s) r v • 4a-Q9wo P.O. Box 1504 APPLICATION ONLY Building e^? js � _ / ' 7�105 GALCALIFORNIAESTAD9 Address J J N LA QUINTA, IORNIA 92253 Owner S City lZip ITel. State Lic. (City 8 Classif. (p3� Lic. # Arch., Engr., Designer Address Tel 6:370 Cit 1 Zi State 1 / � p PZ116 JLic.# e/g?3 7 LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. SIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5.Business and Professions Code: Any city or county which requires a permit to construct, alter. improve, demo!:sh, or repair any structure, prior to Its issuance also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. or thathe is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500). i : I, as owner of the properly, 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, Suisness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees, provided that such improvements are not intended or a ed for sale. H. however, the building or improvement is sold within one year, of comple � n, t e owner -budder will have the burden of proving that he did not build or improve for the our se o% sale.) ! : I, as owner of the property, am exclusive) contHes 9—– Date ractors to con- struct the project. (Sec. 7044, Business an Prolisor's License Law does not apple h c owner of property w buil owho contracts !or sucn projects with a contracror/s) licensetl p suant o thw.) I am exem t under Sec. P.C. f Owner Ihereby affirm that I have a certificate of consent to self-OLA,or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (S 00. Labor Code.) Policy No. Company "- Copy is filed with the city. is Certified copy is hereby f nished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation 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. Date Owner NOTICE TO APPLICANT: ff. after making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued: (Sec. 3097, Civil Code.) Lender's Name Lenders Address This is a building permit when properly filled out, signed and validated, and is subject to expiration it work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. ! I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter the above. mentioned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip Sq. Ft. No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ �Ir Estimated Valuation PERMIT AMOUNT k 1 Plan Chk. Dep. Plan Chk.,Bal.t Const. Mech. Electrical Plumbing S.M.I. Grading Dr'ive-way Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date Permit Validated by: Validation: "' ce"VI BUILDING: TYPE CONST. OCC. GRP. Mailing Address 4,, s() ' 141d, A.P. Number Legal Description Project Description City _ Gk ( V/,t, Zip Z�j Tel. �� /�� Contractor S City lZip ITel. State Lic. (City 8 Classif. (p3� Lic. # Arch., Engr., Designer Address Tel 6:370 Cit 1 Zi State 1 / � p PZ116 JLic.# e/g?3 7 LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. SIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5.Business and Professions Code: Any city or county which requires a permit to construct, alter. improve, demo!:sh, or repair any structure, prior to Its issuance also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. or thathe is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500). i : I, as owner of the properly, 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, Suisness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees, provided that such improvements are not intended or a ed for sale. H. however, the building or improvement is sold within one year, of comple � n, t e owner -budder will have the burden of proving that he did not build or improve for the our se o% sale.) ! : I, as owner of the property, am exclusive) contHes 9—– Date ractors to con- struct the project. (Sec. 7044, Business an Prolisor's License Law does not apple h c owner of property w buil owho contracts !or sucn projects with a contracror/s) licensetl p suant o thw.) I am exem t under Sec. P.C. f Owner Ihereby affirm that I have a certificate of consent to self-OLA,or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (S 00. Labor Code.) Policy No. Company "- Copy is filed with the city. is Certified copy is hereby f nished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation 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. Date Owner NOTICE TO APPLICANT: ff. after making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued: (Sec. 3097, Civil Code.) Lender's Name Lenders Address This is a building permit when properly filled out, signed and validated, and is subject to expiration it work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. ! I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter the above. mentioned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip Sq. Ft. No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ �Ir Estimated Valuation PERMIT AMOUNT k 1 Plan Chk. Dep. Plan Chk.,Bal.t Const. Mech. Electrical Plumbing S.M.I. Grading Dr'ive-way Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date Permit Validated by: Validation: 2--2cl --c7 4P t 2-