BLDG (0301-230)jr LICENSED CONTRACTOR DECLARATION
1
I hereby a. irm:under penalty 'Of perjury that I am licensed unde'r.'provisions of
r,C ptgr-.9'(c rnmending with Section 7000) of •Division 3 of the Business and
N W ._P.. -if ssionals Code, and my License is in full force and effect.
License.?- Lic. Class Exp. Date
,r.
-'� o ,Z Date tr Signature of Contractor
ti F= `. OWNER -BUILDER DECLARATION
W W I hereby affirm `under penalty of'pOju`r that I am exempt from the Contractor's
a s License Law for the following reason:
N
' Z_ V) . I, as owner oftthe, property, or my. employees with wages as their sole
' compensation, will do the work, and the structure is not'intende'o,or offered for `.
sale, Sec 7044,. Busihess & Orofessionals Code /
( ) I,,ras owner of_ithe property;am exclusively contracting with. licgsed
' contractors to :construct the Project, (Sec. 7044,'•Business & Professiohals-
Code)
NS V
' co ( ) I am exempt ltnder Section ;' B&P C,.,.for--this reason � '
N :`Date .+`' x a:r «! -,$ignature of Owner " .% �,T. `j ,1
QWbRKER'S COMPENSATION DECLARATION
F hereby, affirm under _ penalty of perjury one of the following declaraJionsr
Yr H�0 1 _••r: O 1•6ave and,=will maintaina.certlficate of consent to self -insure for WOr,RCers��
N5< w. compensation ;a',proVided for'by, Sbdtion� 3700 of the LaborXode, fp'F the!/
perfo'rmance of, `the work, foewhich'this permit is issued.
('') I have and willlmaintaln workers' compensation insurance, as required by
! O� Q Section 3700 of the Labor Code; for the performance of the work. for which this
permit is tissued ; My workers' compensation insurance carrier & policy no.'•are:
tp f`Z Carrier' Policy No.
Q (This section need not be completed if the permit valuation is,for $100.00 or less).
I certify that ii ;'6 performance of the'twork for whichthispermit is issued,
I shall not employ any person in any manner so as to become'subject to the
{.r '•workers,,compensation'laws of California, and agree that iflahould become
A'^ subfect to'the workers' compensation proyisions�of Section 3700 of the Labor
3 Code I shall forthwith coin I with those provisions.
t Date: '.S ray Applicant
Warning: Failure to secure Workers' Compensation covera9e is unlawful and
ay 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 37.06
\'` of the Labor Code interest and attorneys 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. : y
1. Each person upon whose behalf•this,application is:made & each person at
whose req"ue•st and for whose' benefit'work is performed under or pu'rsuant fo
any permit issued as a result of'this applicaton'agree`s to; '& shall; or
'
& 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. l,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. .
Rinnntnra 'W)wnar/Anantl . :ay.. - r4 :a�...z Date o
PERMIT #
RL11ILDING PERMIT .w
e
DATEVALUATION LOT TRACT
JOB SITE ADD ESS ;:. 54,4W. i6vE,( W MXM) AZA
APN' _
OWNER '• t '
CONTRACTOR / DESIGN ER1,EN (NEER
4.155 E1NT0,1 AMMOZ-
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LA QUMA C � f 9,���,s'
USE OFF PERMIT
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19 LF Y, CWZ1DXN' 3?iPAt,8 J Y:k4' G 149N WA1,UA.i4 PZRII1TY
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:C MWATEA C:O"P1'
rJ5 2003
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OF LA,QUINTA
CITY .
FINANCE' DEPT
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RECEIPT
DATE „ • /
8Y"
DATE FINALED
INSPECTOR
_ rr
�,t. ✓'' ,, r ,�s 4
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 4 77 c 3 �Gl
Electric Bond
Footings
Main Drain
Bond Beam _�� p _ (l/
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
'Waste
Waste Lines
Piping
lumbing Top Out
Heater Final
Plumbing Final
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:
1 14 1
.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 yoirshould 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 orCounty. 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.gr more for the entire pioject, and such 'persons are not licensed as contractors or
subcontractors, then you maybe 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 rtax withholding, federal social security._ taxes, worker's
compensation insurance, disability insu"ranee costs and unemployment compensation contributions. — - —
There maybe 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 Stair
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 LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7
F
ER' S S ATURE /DATE
PROPERTY ADDRESS
e301 -a30
PERMIT NUMBER(s)