BLDG (0107-309)53580 Avenida Martinez
0107-309
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 1=xp. 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 exempt under Section , B&P.C. for this reason
Date Signature of Owner
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 v:orkers'
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 to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: <. Al •, > + 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.
r Signature (Owner/Agent) .-Eirrs• ' y=FA7`l ,,err Date!f'.T /
BUILDING PERMITe
=`'PERMIT#
DATE / VALUATION LOT
r j'%- 3 j TRACT
l(/ 1
JOB SITE
ADDRESS
APN
7e su1 "A'-yb,) 'ppvvApYY1`y\ ` 1 y .L l hY
. '.«T'4 JV4J+ o- irAbf.7fd aCAf'i3cf.Jf ii47.lY .e
- ^
OWNERh`
CONTRACTOR/DESIGNER (NEER
W7Jo P NA1"o
OW)ORBrLy/EN
I A Quwu CA !Mss
USE OF PERMIT
i
31)L.F5'MRMNWAtt.6c:1'!Y,.i1rArti?A1ZV
lul
1t J
L 30 x001
Ci_w
OF LA QUJNjTA
ifdWgCE DEPT
HSIM-91rLD COST M CO.N MOM(M
649.50
Fico S'?iMM"'X
COM1, 11LICT10,1 i FEZ 101-W-418-000 $19,00
►St7B-T•;7' °PL Ct7WT1 UCIION AND Pr.waN (,WCK
;$19.00
IX 33 PRE -PAM 1MES
$0.00
7?Ca"i',1 L PERAM I KE6 :Dul NOW
$19.011)
RECEIPT
DATE
as
BY
DAP.I' FNAL
V/
INSPECTOR
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 Wail Insulation
Condensate Lines
Party Wall Firewall '
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs /_
Footings - 3c�T
Electric Bond
Main Drain
Bond Beam o f s�
c
Approval to Cover
Equipment Location
Underground Electric
Final �Ql S�
PLUMBING APPROVALS
Underground Plbg. Test
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
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 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 •t200.00 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 Quinta, CA 92253
(760)777-7012
FAAK (760) 777-7011
e
OWNER'S SIGNATURE/DATE
317v D l/Ei✓ /7i9
PR(5PERTY ADDRESS
f o )-302 NUMBER(g)
c&*ty./ 4
Address
53-580 AMENDOZA
Owner
BILL FLENIING
Mailing
Address SAH E
City LA QIINNTA, Z'92253 Tel:
?IG1NTR E—EA6 S
Contractor
P.O. BOX 1504
78.105 CALLE ESTADO
LA OUINTA, CALIFORNIA 92253
Address
46-301 ROUDEL LANE
CityTel.:
Zip
LANIQUINTA 92253 342-3521
State Lic. City
& Classif. C53-614611 L 1945.
Arch., Engr.,
Designer
Address
City IZip I State
Lic. #
LICENSED CONTRACTORS DECLARATION
I 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 Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, atter, Improve, demolish, or repair any stniclure, 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 that. he 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, as owner of the property. or my employeeb with wages as their sole compensation, will
do the work, and the structure Is not Intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Lew does not ,apply to an owner of property who
builds or trnproves thereon and`.who does such""& himself or through his own employees, ,
provided that such Improvements are not Intended or offered for sale. h however, the building
or improvement Is sold within one year of completion, the owner -builder w® have the burden
of proving that he did not build or Improve for the purpose of sale.)
O 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's- License Lew
does not apply to an owner of property ,who builds or Improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed ff 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, C/O Code.)
Lenders Name
Lender's Address
This is a building permit when property filled out, signed and validated, and is subject to
expiation It work thereunder is suspended for 180 days. '
1 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
No. 11256
LDING: TYPE CONST. OCC: GRP.;
P. Number
;gal Description ;;• ;.:a,:.ii, ;,r:? .:i; 7 r:: ;;:
oject Description 'POOL ONLY
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
1
surndlea vaiuduun
$10,000
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
76.05
Const.
117100
Mech.
214 . 0 0
Electrical
45 . 010
Plumbing
27.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
2 -
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:
7/3t/ga LO
clec