SFD (9905-050)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
59465 r {1.:7 21yi-M
-
,date- Signature of Contracto yf
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 einployees 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). ,
1, as'owner of the. property, am exclusively contracting with licensed
contractors to,construct the project (Sec. 7044; --Business & Professionals
Code). '
O 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 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
S ction 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.
9106
s w o r. S:�tt1 cn c
(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 shalkhot employ any person in any manner.so'as to become subject to the
workers' compensation laws of California, PAcl agree that if I should become
Subject to the workers' compensation provisions of Section1'37i,00 of the Labor
Code,i'shall forthwith'comply with those p ovisio'nt. '
I Dater . 1 I 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 personupon 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 trepresentatives of; t is City to enter upon
the atiove mentioned property for spection purpose
S
r
t
Signature (Owner/Agent) Date
BUILDING PERMIT PERMT#
DATE VALUATION Ff n YY tf 'VL7 60�f LOT " ' TRACT
2.84; 8-1
JOB SITE
ADDRESS '11:4411 �l QU�l
APN
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
n n�i nz tCy�'`AR{� D[[ t,�}'+r 11•i n_.('r„MIT /+%�s���
i'.1`\S vA,,..ak.l.J .t,J.1r Q.f-.bu PtVAi.:A �.F .+oil
�'7' '� 'J'aP�n CNA' T{r to SM f rail
1 \�` A4?..IA CR(.. /_ 4�� 1,
78.613 NAME'S liftIVE
1861.3 NfAPL%S Dk
LA, QL11.1V'1A CA 92253
1..A QX11NIA CA 92.253
(76qM?••027.2 C110i 5750
-
USE OF PERMIT
Sl�..;_.LL i�l\n�ILY I.)�'ELLINCi.
3If`D - LUDO 33 PLAN M,- PERMIT :DOES NOT liva'LUDE':II:.00K WALL OR
RCK)L.
TIV CT 00111-kWC'TI.ON 1,914.00 Sir
1°fJRe A'rto 'Pei,t?1) SF
0ARAOXVC6i.t'Zt10H.T 409.00 3F
T1. In Cos
.VS MATE ST or COAN-STIRIUCT1.11"'IN
IF 61344)
CONST U'G f10N FEE 10.1µ000 -418 -WO $671.0)
PLAJl va•1?-C> FEE' 10! -(1415-QA9- 41.£# S555.42
1.01-00.42.1-000 W?.06
r-1-aG'CRIC;..AL:-mz lOi bi1O-=1ZO.000 $120.t�`t
PLUMBING ING Fid, 101.-0OO-41v-000 S!A-4."Is
la DINQ NiM1OI" PIES - R1?S;D 011-000-241-W S Q.86
GRADING £tom I10f-000-423--0gO $11W.00
iNFRA,3'i kl:ltCJVURU F0 L� 5-000-443- t47
Aia F'W X"UB1,1C PLAC HS - 1W SIL 701-060.2 55 -OW
SUP -TOTAL CONS'T'RUCT -100, AND PLAN CHECKS4..M2.49
. LESS PRE-'A.ID 1'1;1'::
PR -Pj
9 t d A� 9 x ¢' �a 7y aP�
TlJ���fO..Hr .l��a`'IRM�Y.V A'.Er�� S 1fAC1Ai'' 1.4Q.JV,`'
MAY 1 fro" 1999 s
$4102.41k
RECEIPT DATE BY' DATEFINALED INSPECTOR
INSPECTION RECORD
O-PERATION j
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
i — , va
F.A.U.
Framing
,_/
Compressor
Insulation
— %qD
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
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Z Q9
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out .
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer LateralPool
i"
Cover
Sewer Connection
7
Encapsulation
Gas Piping
Gas Test
�®.p
Appliances
Final
COMMENTS:
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)
AF,'_q-18-2000 09:4? WESTERN INSULATION 909.686 8786 ,,P.05/13
.�. ... ;
WESTERN INSULATION, INC.
42 l 1 Latham Street, Riverside, California 92501
Td. (909) 686.8760 Fax (909) 686-8786
INSULATION CERTIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:
TRACT / PHASE: BELLA VISTA - TRACT # 28458-1
LOT# 33
SITE ADDRESS: 43610 MILAN COURT-
EXTERIOR WALLS - - - - -
MANUFACTURER: Johns -Manville THICKNESS: 3 5/8" R -VALUE: R-13
CEILINGS: BATTS BLOW
MANUFACTURER: Johns -Manville THICKNESS: 13" R -VALUE: R-38
-CEILINGS: BATTS BLOW
MANUFACTURER: Greensrone THICKNESS: 10.3" R -VALUE: R -38
l -
-----------------------------------------------------------------
GENERAL CONTRACTOR: TRADITIONAL BUILDING
LICENSE NUMBER: h
BY:
TITLE:
DATE:
INSULATIONCONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 481278
BY:
TITLE: P OD CTION MAN GER
DATE April 17, 2000
um
ROGER SNELLENBERGER DEVELOPMENT
78615 NAPLES DRIVE
LA QUINTA, CA 92253
(760) 772-0222
(760).772-0257 FAX
TO:
Apex Interior Source
Unit Price Total
79-553 Country Club Drive
Furnish the following upgraded window covering
Bermuda Dunes, CA 92201
Fax:
360-3167
Attention:
Denise
Lot & Phase:
Lot 33, Phase 5C
Date Required :
ASAP
Requested by:
Rita
Desiqn Center
PURCHASE ORDER #
9020
April 20, 2000
PROJECT: Bella Vista Phase 5
Ship to: 43610 Milan Court
La Quinta, CA
Homeowner: Hensen/Germ
Cost Code: 3186
Hours
Material / Work Required
Unit Price Total
Furnish the following upgraded window covering
Premier verticals throughout
$ 1,954.00
$ 1,954.00
Fresno White
15) Verticals
4) Horizontals
Horizontals with Privacy
TOTAL
$1,954.00
special conamonsnnstructions:
Roger Snellenber er Development
C.
n Center
AUKNUWLEUGE AND RETURN
Apex Interior Source
By:
4 {Y
Bin #
Qty of La • Quinta .
Building 8T Safety. Division,'
P.O. Box 1504,'78-49.5.0 alle Tampico
La Qitinta, CA' 92253 - (60) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: 4 j �fJ U
Owner's Name: -)VU a e, C
A. P. Number:
Address:
Legal Description:
City, ST, Zip: LA Ou) NTA n C -A q as s
Contractor:
.Telephone:
Address: i , 1 C-}
Project Description:
City, ST, Zip: L ). A CA `I AA 53
,: --0- 5
Telephone:%o 50, / 3�
y ;. ;:::::: ; M ::
L�
State Lie. #.: A/ /-A
City Lie. #. f41A
Arch., Engr.,' Designer:
Address:
City, ST, Zip:
Telephone:t!^`:
State Lie. #:
w
€�';�•�:s„�:«;;;,;��....`�`,�,'.�•�' •� �
Construction Type: Occupancy:
Project type (circle one):' New Add'n Alter Repair Demo
Name of Contact Person:
.,Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: Q()0
APPLICANT: DO NOT WRITE BELOW THIS LINE .
#
Submittal
Req'd
Rec'd
TItACIONG
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
Structural Cales.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cales.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Pians picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2w° Review, ready for corrections issue
Electrical
Subcontactor List
Called Contact Pelson
Plumbing
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted
Grading
IN 11OUSE:-
7n/ 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
P:O. BOx -1504
LA QUINTA; CALIFORNIA 92247=1504
78-495 CALLS TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
(7'60) 777-7012
FAX (760) 777-7011
PROPERTY OWNER'S PACKAGE
Disclosures & Forms for Owner -Builders Applying for Construction Permits
MM
Q.�T,MT! l�[QTiCI� W PRQPTRTY QVVI�TER
Dear Property Owner.
An. application for a b • .
wiling permit has been submitted in your. name. listing yourself as the builder of the . property
improvements specified at
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you awwe.of your
respe8srbilities and possible risk you may incur by hgviag this permit•issued in your time as .the
Owner -Builder. We will not issue a buil ' y read, initialed your. understanding of each`provislon,
drug p�elrmit until oa•have
signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
UVVMH'S AC LEVq?AM ANIS 3M CATION OF WFOMAMN
�,D&�ECT7M: Read and initial each statement-bdow-te stgmfy you
rr lsersYand or vet�y lets irejormextion
I" h. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
building permit that erroneously implies that the property owner is providing his or her own labor and material pesumalty. I, as
an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property My homeowner's insurance may not provide coverage for those
mJuri� I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
'on my. property -
ML 2.
roperty
M2. I understand building permits are not required to be signed by property owners unless they are responsible for the
construction and are not hiring a licensed Contractor to assume this responsibility..
3. I understand as. an "Owner -Builder" I am the responsible.party of record on the permit. I understand that I may protect
myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
(, 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
A16. 6. I understand if I am considered an "employer" under state and federal taw, I must register with the state and federa
government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemploymen
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financia
risk-
M6-
isk
M6- 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residenti;
structures cannot .legally build them with the .intent to offer them for sale, unless all work is performed by licem
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perform
under contract with a licensed general building Contractor.
�8. I understand as anwner-Builder if I sell the property for which -this permit is issued,I maybe held liable for any
financial or personal. Igjarics sustained by anysubsequent owners) that result from any latent constnrction defects .in the
worlananslup or materials.
/
' Y1 lT 9. I understand I may obtain more information regarding my obligations as an "employee' from the Internal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial • Accidents. I also understand I may contact the California Contractors' State License Board (C3LB) at I-
800-32 I-CSLB
-800-321-CSLB (2752) or www.osib.ca.gov for more information about licensed contractors.
M6-10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party legally and financially responsible for proposed construction activity at the following address:
agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Ow, ner-Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions; deletions, or chgoePs to any of the information I
have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a licenser Bre Contractors' State License Board may be unable to assist You with MY financial loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be iWcivil court. It is also
important for you to: understand that if an unlicensed Contractor or employee of that individual or Fam is Wjaued while wonting
on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder mud wish to lure Contractors,
You will be responsble for verifying whedw or not those Contractors are properly licensed and the; status of their wmke &
compensation insurance coverage.
Before a building permit can. be issued, tbls form must be completed and signed by the property owner aed returned to
the agency responsible for issalft. 6e.permiL Now A copy of the p vperty owner's dWyer's Akettsej fw= norma; or
Other verifucadon acceptable too the agency is required to be presented when the pmnit is iasuad to M* the' property
owner's signature. ^ I
1
,I
�► tee. e e ee.;+ a e> �'' I I I `��
Note: Thefollowing Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY 0"UR'S RAF
Excluding the Notice to Property Owner, the exMg ion of which I understand is my personal responsibility, I hereby authorize
the following perser 0 to act as my agents) to apply for, sign, and file the documents necessary to obtain an Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work):
k r 1 , e
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the abo•
information and certify its accuracy. Note: A copy of the owner's driver's license, form hotariuuion, or other verification
acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature..
Property Owner's Signa Date:
43u►oN
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