BLDG (0403-376)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
Professipnals C6G:e, and my License is in full force and effect.
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, 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):
p,'i am exempt under Section , B&P.C_for-thireason
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
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-p.ovlslons.
Date: 2. 4r—c>;1 A Iicamt'r
Warning: Failure tc 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 inspecion purposes.
Signature (Owner/Agent Date
BUILDING PERMIT PERMIT#
DATE ^ 031/25/1 VALUATION � � LOT TRACT
w
JOB SITE
ADDRESS J'-:a���e6,f�sV.�i�l.F.�eltA.l,tlr"SV�!�.c47��,+
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
T_3, VE. 80-INIMT
CVA.HR- /E,7:dMMI
L QUIN TA CA 92233
USE OF PERMIT
193 Lys'. 6''H104 OARDEN UV`ALL. CITY STANDARD
6 FT. WAIJ, 10.90 g.,i+
)'-'—S .Ct 17a :, V.oS i' or, co.m "mumon
CON TRILIC3 OM FER 101-000-418-000
ST_M OT�lC:CJP3:STRITCT-0,K.AM, •Ate CHECK
$"i'2,00
6 n .ESS 1PRE-PAID FnS
so, 0o
EMAR, 5 2004]T
CITY OF LA. QUINTA
FINANCE DEPT.
RECEIPT
DATE/BY
DAT FINALE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slau 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 Q
Electric Bond
Footings
Main Drain
Bond Beam G
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING ApPhOVALS
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:
Ettf't
1.
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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 yoti 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 of 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,sD_ecific_information_about_vout oblieations under Federal Law, contact the Internal Revepue Service (and, if
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