PLBG (9612-123)} ' ' LICENSED CONTRACTOR DECLARATION, ,
I'hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9,k(commencing with Section 7000) of Division 3 of fhe'i3usiness and
Professionals Code, and my License is in full force and effect.
r 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, gr -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
Eontractors to construct the project (Sec. 7044, Business & Professionals
Code). ;
1°am exempt under Section ((B&P.C�,;7for this reason I n
ate _?,t >..' C. Signatute of Owr?er-9.1b,,, /7r.,, . ,,. `
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 tc 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).
( jkrcertify 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 Se6ti6n,3700 of. the Labor
Code, I shall forthwith comply`with those provisions. , /? k • /
VDate: thg, 2 fi f. Applicant -. /11// /i1,A 41, L/ r'
Warning: Failure to secure Workers' Compensation, coverage is unlawful and
shall subject an employer. to criminal penalties and civil fines up to $100,000Jn
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.lf
work is not commenced within •180 days. from date of issuance ofil uch
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 T
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 f � inspection purposes./M ,
ignature (Owner/Anent.) � ` � f,�' f%! Date 1�
BUILDING PERMIT PERMIT# ;.• . CONTROL#
DATE , ����t�ttf� VALUATION ���«a�{d LOT, TRACT
ADDRESS 53-204) E .V0410A ,'°f'�.���IIXY� JOB
APN , "]"fid �trh���.�4) }
OWNER
CONTRACTOR/DESIGNER/ENGINEER
_.OWNER. Br_{.t
'.
CIS
USE OF PERMIT
INSTALL $'td,':i•!°Fii3� L"S k'O f}c�i:il
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�.. LESS PRE PAfD t1i;�S
$0.00
RECEIPT �*
DATE
BYd
DATE FINALED
INSPECTOR
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 - IM. 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:- , 4
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 6 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 regisier 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.
r -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 ate 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
78-105 Calle Estado '
La Quinta,. CA 92253 .
(619)564-2246
FAX: (619) 564-561 ,
OWNER'S SIGNATURE/DATE 4
PROPERTY ADDRESS
t 23.
PERMIT NUMBER(s) .
CITY OFLA QUINTA
17,
BUILDING & SAFETY DEPARTMENT
CONOMONALLY
ACCEPTED FORCONSTRUCTM
SUBJECT TO INSTALLA11ON AS PER
'AND ALL APPLICABLE CO ES
DATE
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