BLDG (0303-323)44095 Mariposa Ct
0303-323
LICENSED CONTRACTOR DECLARATION
|he,eby affirm under penalty of perjury that |amlicensed under provisions of
Chapmrn(commencing with Section 7OuOofDivision 3ofthe Business and
Professionals Code, and myLicense ioinfull force and effect.
License # uv.n/000 Exp. Date
.
Date Signature of Contractor
17
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am' )xempt from the Contractor's
License Law for the following reason:
1, as owner of the property, or my employees with wages as their sole
pensation, will do the work, and the structure is not intended or offered for
(as
Sec. 7044, Business & Professionals Code).
AqWner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
CoUe
---
I am exempt under Section B&P.C. for this reason
Date
Signature of Owner -
i WORKER'S COMPENSATION DECLARATIO
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to s lf-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 b
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 nthe permit valuation is for $100.00 or. less).
()|certify that inthe performance of the work for which this permit s* issued.
| oxan not employ any person in any manner uuavmbecome subject mthe
workers' compensation laws orCalifornia, and agree that if | should become
subject mthe workers' compensation provisions ofSection 37UOo,. the, Labor
Code, I shall 6m - '
Date Applicant—
Warning: Failure to secure. Workers' Compensation cov.erag.e 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 3 .06
ofo aUo,Codo.imo n undaom
oe o eo
m ,
IMPORTANT Application iohereby made mthe Director of Building
for a ponnn subject to the conditions Ad nvmhnUono et forth on his
application.
1.Each person upon whose behalf this application ismade & each person at
whose request and for whose benefit work ioperformed under mpursuant m
indemnify
& hold harmless the City o/LoOuintu. its officers, agents and employees.
o. Any ponnu issued as result n,this application becomes null and void if
work is not commenced within 180 uoyo from uoun of iaau*nvo.m such
permit, o,cessation cf work for 1oodays will subject permit to cancellation.
|oortify that | have read this application and state that the above information io
oo,noot. | agree mcomply with an City, and Gxato/aworelating tothe building
uonstmmion, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpouo» .
^ ]
-Signuuum (Ownodxgont)oav4' -
°
Bul '11-63h
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
44,09,4,j,"A!ARV05A
11114
USE OF PERMIT
AN r11 1'9
now
00,MSTRUCTION FEN- '1101 -0100j-4 38-000
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
OX 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 -SPA S
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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/ 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 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 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.
f
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.
t 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 Stare
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. i
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 ILA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012
FAX (760)
OWNER'S SIGNATURE/ DATE
f D 9J /1'1 ti/•°a C_j
PROPERTY ADDRESS
..Q3v3 - 323323
PERMIT NUMBER(s)