0205-243 (BLCK)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
contracters to construct the project (Sec. 70441;' B'us 9ess'-&xProfessi6rials
J$ignature of Owner �`,�
ER'S COMPENSATION�DECLA(A ION
I hereby affirm under penalty of perjury one of�the �fdllowing-Ve-clarations:
() 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).
( 1 certify that in the performance of the work for which this permit is issued,
I shall not employ any person in anyo,manne so as to become subject to the
workers' compensation laws of Califorriia, aydJagree at If I should become
subject tot 'e wor� rs' compe �s,ation rov s sof Se U n 00 of the Labor
a sr i
Code. 1 sbafHorthhithcomply with�ihose,pr vtslons. Zo
Warningf Failur; to secure Workers' Cornpensati • n covera9b Is unlawful and
shall subject an employer to criminal penalties•a d-civikfine 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
correct. I agree to comply v
construction, and hereby at
the above-mentioned prop—e)
Signature
Ali"cation al�d state that the above information is
all City, ajd Statp laws relating to the building
n}; r re�sentatives,of this City to enter upon
51i t♦'on, ur sses. ,y
Data'
BUILDING PERMIT . PERMIT
DATE ,y VALUATION LOT' TRACT
JOB SITE
ADDRESS S"69l
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
if'3:C310>t3.:iA li..OZANO
OWM91 "U?;Y.zy"R
54.860 AVRINI .A.CJ:l3,K9GON
USE OF PERMIT
64T. '6 AV4-till. (9) XX
fM_NS4rAVi:1'fC9I` IT"S 1034=4.19-@',if1 ?5+F- ►
f
1AY�
CITYOFIAQUINTA
FINANCEDEPT.
91B-TG)"4'.dL 60i+lMUC:' ION AND HAN Colo
W-9.0
TC+Ayli L IvAMMY fKI9.?.8 L U ,, NOW
529.0
RECEIPT
DATE�� C! �� 2
,
BY
D E FI l
INSP R
..�
+, a,, 7
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
f
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
WF ste Lines
Heater Final
Witer 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:
Bin #
City of La Quinta
Building 8r Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 "(760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
0 Z
Project Address: -t5q —ao V. 06/MOI�
0%%-ncr'sName: -*-111clorla 14-)>0f?0
A. P. Number:
Address:* 6 &0
Legal Description:
Contractor:
City. ST. Zip: 19 2,?
Telephone: -2 av
Address:
Project Description:
City. ST. Zip:
Telephone:
State Lic. #: Citv, Lic.
Arch.. Engr., Designer:
Address:
City, ST. Zip:
Telephone: ..............
... .......
State Lic. #: ... ...
Name of Contact Person: Y7
Construction TN pe: OccupancN-
F
Project t -,pe (circle one): Nc%%- Add*n Alter Repair Demo'
Sq. Ft.: # Stories: 9 Units:
1E
Telephone # of Contact Person:
Estimated Value of Proiect: A -
APPLICANT: DO NOT WRITE BELOW THIS LINE
Submittal
Rcq'd
Rec'd
TRACKING
PERMIT FJEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Coles.
Called Contact Person
Plan Check Balance
Title 24 CaIcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
SAM.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P,
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
6//
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/ Builder" you are the responsible 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
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 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 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 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 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 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 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 may be obtained by contacting 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 the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico - - - -
La Quiru r, CGA 92253
1: ) ' 1 vv ? �5 -Li (.,
OWNERSIGNA /D E
4:241 . 61, o,
PROPERTY ADDRESS
o�o5--z�3
PERMIT NUMBER(s)
Site Requirements for:
Interior Lot
SIDE YARD: S Feet REAR YARD: 10 Feet
Minimum, Each Side, Minimum
rr
17( OF LA QUINTA
_� E)INN & SAFETY DEPT.
APPROVED
FOR Co STRUCTIOIV
DATE -5 G 7 �gY
FRONT YARD:
20 -Feet
Minimum
' I I
1 ,
I i`g
,
I
..I
AREA TO 'BE i
-: --LAMSCAPED
PROPERTY
LINES
5
CURB LINE