0401-288 (PLBG)LICENSED CONTRACTOR DECLARATION
j 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
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). - _/
() I am exempt under Section B&P.C. for this reason
Date �. �' ' t Signature of Owner'
WORKER'S COMPENSATION DECLARATION
I hereby affirm, undeJ penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, I k as provided for by Section 3700 of the Labor Code, for the
performance oNe 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.
1his.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 sliall 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.
pate: 1" l Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
i
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
`r,.Sij`hature (Owner/Agent)-- Date'- � �1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 040 1 - 28S1 TRACT
JOB SITE v
ADDRESS 52-420 AV'I'L'.NWA RUBIO
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ha
52-420 AltFMIDA RUB1n
LAQjJR4TA clk 912253
() - M3L.4
USE OF PERMIT
FLUMMING
ADD CTAS LINE TO HOUSE FOR FIRFPLACF, DRYER AND WATER. H4Lr.P.T9k
OH/t.140E 00T WATR-P, HEATER
V AL.IIA'TION3�.4� 1,
RISTMA ED COST 010 CONYMUCTION
:32.00
}'Ltlmrtrwa FT101-000-419-000 V!,$o
D � D
JAN 2 0 2004
CITY OF LA QUINTA
FWANCE DEPT.
SUB-I'GrAL c'oN�1rt�tic°11C,I�I. NI3 �LAla r r ;c a
�? 50
LASS P.RF-PAID ;FEE19
$O.OD
TOTAL Pk,.R1Vi1T FEES DUE NOW
$.21.150
RECEIPT
DATE
a/
BY
D FINA L
O
INSP
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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground P!bg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbir4," Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer La. ral
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
Fbdures
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:
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
t('*'6 -p"r; 6 pe r t y I :own . er sth , ess't they Orrsonally performing their
permit. Buildingpermits are not required 6-1 e h I
own work. If , you I r works is bein I 9rPerfqrihed �by.;s6me6n6_.'_otherthAn yourself, you may protect yourself from possible
liability if that person applies for 'the `p'x'6p_ei-permit in":his"'Pr'her. name.
Contractors are required bylaw to be licensed and bonded. by the State of California andto have a business license
from the City or County. They are also required aw
by':l to,.put 'their license number on all permits for which they
apply.
If you plan to do your own work, with the excepti6n-'of.vario-us 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 oi.her'than:yoor immediate family, and the work (including materials
and other costs) is- $200.00 or .more `for the' entire °p`riojecv, and -such* persons are nor licensed as contractors or
subcontractors, then you may, be an employer.
If you are an employer, you must register. with the State and.Fecleral-Goiver ' nment 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, disabijity.,ins rance costs arid undnbl0rnent compensation contributions.
There may be financial risks for you 4f you do not carry . out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific informationabout your'obligations uriderTederal Law, contact the Internal Revenue Service (and, if
you wish, the U. S. Small Busines's Adminstiati�6n)`Nr more spetifie.information about -your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.,
If the structure is intended forgale, property owners who are hoi.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
m
perit, erroneously implying -that the property owner , . -'
is providi nj -his or' her - own. labor and material personally.
Buil . ding permits its a. . re 1, not required . to be -signed bj* property roperty owners unle"-ss'they are' performing their own work
personally.
Information. about licensed contractors,may bq.obtiined-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-bu; ildef. 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 0253
(760) 777-7012
FAM -(760) 77i-9011
OWNED SIGNATURE/DATE V'
PROPERTY ADDRESS�
PERMIT NUMBER(s)
Cie
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Item
Model
No.
Numbe.
u
1 04 T.
123 7
FGiJ4040 .
Nominal
FG1H4 40S3N0V
40
Gallon
51-3/4'
.................
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40.5
' 0:55'
Gallons
4DiametirCapacity
- 3-4
188418
BTU Gas Per. Hour
Energy Operating Cost
Vent
Family
Input, ' T pe Recbveiy**.
50
Diameter Other
Size
50
'0:56" .161
- -
3 -
3-4
--
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0.5
40
`y
FG1H4 40S3N0V
40
r 20
51-3/4'
.................
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40.5
' 0:55'
Gallons
Annual
- 3-4
188418
BTU Gas Per. Hour
Energy Operating Cost
Vent
Family
Input, ' T pe Recbveiy**.
Factor f Per Year)***
Diameter Other
Size
40,000. Natural `,.. 40
'0:56" .161
- -
3 -
3-4
--
. -.
0.5
40
1g 1 u e
61-1Z2
40,000 Natural 40.5
0.55: 164
3 -
5
-40;000 Natural 40.5
0.55 164
3 1 High Altitude
5
FG1H5040T3NOV
50
z 20
.60-1/4-140,000`
40;000;
'Natural
40.5''
0.55
145232
FG1H4 40S3N0V
40
r 20
51-3/4'
40,000
Natural'
40.5
' 0:55'
164
3
- 3-4
188418
FGiH4040T3NOV
40
18
61-1/2
40,000
Natural
40.5
0.56 ..
161
3
- 3-4
7193
FG1H4040T3NOV
40
18
61-1Z2
40,000,
.Natural
40.5
0.56
161
3
High Altitude 3-4
188421
FG1H5040T3NOV
50
z 20
.60-1/4-140,000`
40;000;
'Natural
40.5''
0.55
164
3
- 5
7416
F 0T NOV
50 `.
20
60-144
40
-Natural
40.5
0.55
164
3
_High Altitude 1 5
B
211360
FG1F3030T3NOV
30
16
59-1/4.
30,000
aNatural 1
30.4
1 '0:58
1.56
3
-
1-2
.2.1--12364
FG'1130-30T P7'..
.._ 30
_ .1.6.
59-1. 4.
29;000:
Propane
29.4
0:58
2.7.9...
3
30.4 0; 58 t
156.
211446
FGiF4034T3NOV
40
18
60-1 4.34,006
18 ''' ��'48-1 2.:29
Natural
•_34.5"
.0.57
158
3
-
3-4
6077,,
FG2F4034T3NOV. 40
.20
60-1/4.
34,000,
Natural
34.5
0.61
145
3
-
3-4
211448
FG1F4034T3NOV
40
18
60-1/4
34,000
Natural
34.5
0.57.
158
3
High Altitude
3-4
211450 1
FGiF4034T3PV
40
18
= 60-1/4
33,000
Propane
34.9
0:57
283
3
-
3-4
211454
FG1F4034T3PV
40
18
.60-1/4-
34,000
Propane
34.5
0,57-
283
3
High Altitude
3-4
211456
FG1F504OT3NOV
.: 50
20
<60-1/4
40,000
Natural
40.5
0.55'.
164
3
-
5
4220
FG1F505OT4NOV
50
20
t60-1/4-
50,000
-Natural
50.7
0..53-
170
4
-
5
211458
FGIF5040T3N0V
50
20.
: 60-1/4 -
40,000.1
Natural
40.5 "
0.55 "'
164
3
High Altifudel
5
211462
FG1F5040T3 V
50
;=-20
1 60-1 4
40 000
I Pro ane
40.5
'0.55
294
3
-.
5
164961
^ .,
• 76.1
45+
T-
26347
GM57 QNV 75 '26 1-63-1/2 .15 100-Naturat�.
` 76.1
v
5+
®
29554 MHG1F3031T3NV `: 30 16 ''. 59=1 4 °31,000= `Natural' 'JI. 0
eo-
211289
FG1F3030S3N0V
'30`
1-2
MHGIF403IT30V 40 .18� ' 460-114 .31,000 Pro ane 31.0
30,000 1 Natural '-
30.4 0; 58 t
156.
3 j
- 1-2
211304.
FGIF303OS3PV
30
18 ''' ��'48-1 2.:29
000' Pro' ane '
29.4" . ` 6.58:
279
3
- 1-2
211377
FG1F4040S3NOVE40
20
"51-3 4
'40 000 -Natural
40:5 0.55
161
3
- 3-4
211445
F PV
1-3 4'
'3 0'' Pr ' n
0:55
3
3-4
r
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164961
G2F7575T4NOV I '- 75 T+ -"_,26--1j'63__'1/2 I 75,100' '"Natural'
• 76.1
45+
T-
26347
GM57 QNV 75 '26 1-63-1/2 .15 100-Naturat�.
` 76.1
-N A N A 4
5+
29554 MHG1F3031T3NV `: 30 16 ''. 59=1 4 °31,000= `Natural' 'JI. 0
�` 0:56` 161 3
933 MHG1F3031T3PV 30 16 59-1 4 '31,000: , Pro ane 31.0_
E248441
-
� 0.56- 288 3
1-2
MHGIF403IT30V 40 .18� ' 460-114 .31,000 Pro ane 31.0
-
0.55 294
3-4
3 Hi h Altitude
3 4
Limited Warranty - see a Lowe's -sates associate for details. Availability varies from;,store-to
store..
of stocked in this store,'see a Lowe's sales associate. ®Registered •Tiademarli.of Whirlpool, •.U.S.A., "Recovery
Not all models are stocked in every store. For availability of models
is based on 90'F rise. "'Based on the Federal
de Commission's National Average gas cost of 60.44/therm. and the overall efficiency (energy"actor) of`the water heater as tested according
ards. '••'Eavirotempo is
to Department of Energy
a registered trademark of LF Corporation. Envirotemp® models are not manufactured under the Whirlpool® brand.
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