0203-013 (RPL)LICENSED CONTRACTOH'dECLARATIUR-------�---
U) I hereby affirm under penalty of perjury that I am licensed underprovisionsof
Chapter 9 (commencing with Section 7000) of Division 3 of thp,-Bus- ess and
U)
'effect.
Uj Professionals Code, and my License is in full force and
'C,) License #
Lic. Class Exp. Date
LO'! Lu n1l.!-d. r -
ro
ZDate Signature of Contracto
r
0 OWNER -BUILDER DECLARATION
ILL! I hereby,affirm under penalty of perjury that I am exempt from the Contractor's
Z
Z. License- Law for the following reason:
Z
1, 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).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
'Code). I
CV) O I am exempt under Section B&P.C. for this reason
LO A
C\I 6? —Signature of Owner
O'0) 0)
< WORKER'S COMPENSATION DECLARATION
CL
M:Z I hereby affirm under penalty of perjury one of the following declarations:
'CC
0O 1,have and will maintain a certificate of consent to self -insure for workers'
Uj, �L compensation, as provided for by Section 3700 of the Labor Code, for the
< performance of the work for which this permit1s issued.
< 1, 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
U-) �5 permit is issued. My workers' compensation insurance carrier & policy no. are:.
, Z
Carrier Policy No.
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0
(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.: —A�A Applicant r%7,— — . V h,
A-7
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,0001,6'
addition to the cost of compensation, damages as provided for in Section 376,'
I the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and SaJJl1,
for a permit subject to the conditions and restrictions set forth on I
I
application.
1. Each person upon whose behalf this application is made & each person t'
whose request and for whose benefit work is, performed under or pursuant
any permit.issued as a result of,this applicator 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 andwjtiid if
work is not commenced within 180 days from date of issuance- o 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.
Signature (Owner/Agent) - I <Date -1
BUILDING PEMMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
01-ORY COURT
OWNERCONTRAC.TOR
DESIGNER EN61NEER
79•.5 117 MOIZ14IN (i GLORY COVKr
13
79, il DRNJ.'(.FV1.0.RTC(Y0X-V<
1A-QVMTA. CA 92253
`1A QUWTA CA 922.53
750-8014 arsT.4
USE OF PERMIT
POOL AAGNOR SPA
MULAINOSAA ONIIX. MAMSIBA,RXIERS 67,1AAA, 84 IN PIAMt PRIOIRZ
TO 1431.2 PLASTER T.RPM-VON, POOL W.,URPMRINT ENC "11 URE 140T
INI'LtYDEY) 114 OFIRMI.T.
POOL ANDIOR SPA 100,160 IS
X.171MAIV00067 or, CONMUC710M.-
MOM" "I"
IT YJ71k, RUMALURY
PLAY cHr"CK, PRZ
CONSTWICTION FEE tol-000-116-000 $t4g.cm
MECHANICAL FTEZ POOL 101.000-421,000 $24,00
kU?,TRJ CAL, F99 POO-!.; 10149)0-420000 $45.00
PLU'UnT.90 ITFR Pot, 101-000-419-000
r7
:MAR 0 5 igg? J. -'
X.
CITYORAQUIRA
�NT
MUCUMAIN Pk a3FfiK
4 8
FY". 1r.FKM-V DUE NOW
4
RECEIPT
DATE /_./�ATALE
BY
----
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
F.Mal
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Sdt Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
=�? _ Z
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
_
1z
Waste Lines
Heater Final
_
Water Piping
Plumbing Final
_
z
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
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Foctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
'Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
COMMENTS:
TELEPHONE (760) 777-7012 FAX (760) 777-7011
. OWNER/BUILDER INFORMATION
Dear Property Owner:
An application fora 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.mayprotect 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 $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 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 Statc
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 arc 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
F�60) 777: 011.
OWNER'S SIG IVM-URE/DATE 1
PROPERTY ADDRESS
02-3- 013
PERMIT NUMBER(s)
M
~OF
..._.
-.. CITY LA QUINTA• SUB -CONTRACTOR LIST 311 4 -
JOB ADDRESS 7 1�
5"17 Ma r Nr Nc� 6111X cr�
PERMIT NUMBER . OWNER BUI DER I�G✓/✓�
This form shall be posted on the job with the Building
Inspection Card at all times in a conspicuous
dace. Only persons" appear tis list or their employees are authorized to work
on this job. Any changes
to this list must be approved by the Building Division.prior to commencement of work. Failure to comp result in!'a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
.......
Trade: / Classification ...
Contractor
_ _ _ ..
_. _
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_.... _. .._ .:_ t to..Contragtors..License. ...,._: , .: ..............::.::
:.:.... i ::
Workers Com ensat�on Insurance. .:......
Ca. Business;License
Company Name
�'
Classification
License Number •
Exp. Date
Carrier Name
Policy Number;
Exp. Date
License Number
Exp. Date
(e.g: A, B, C-8)
(xxxxxx) /
(xx/xx/xz)
(e.g. State Fund, CalComp)
(Format Varies) rr
(x X, x/xx)
(xxxx)(xx/xx/xx)
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EARTHWORK (C 121.
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STRUCT STEEL (C 51)
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MASONRY IG 291
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PLASTER IC 351...:::
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ROOFING (C 39)
SHEET METAL (C-43)
GLAZING
INSULATION IC 21:
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SEWAGE DIS.P (C421
PAINTING LC 33) "
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CERAMIC TILE IC54)
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POOL':(C 5.i :
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CITY Y OF L1 QUINTA
BUILDING & SAFETY DEPT.
APPROVEC9
FOR CONSTRUCTION
DATE
313-10,L BY