9910-216 (BLCK)LICENSED. CONTRACTOR DECLARATION
I herfLy affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (comeiiencing `buith 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
Dat" a 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).
(,r)' , 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 !i
Date ?/ Signature of. Owner :t .:; i A?A ro ?V i\
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of peejury 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 3.100 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:tlose provisions.
Date:%) -M �7 °% Applicant_('. iY yr. _tel �Y ll_� A �.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of.the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject -to the conditions and restrictions set forth. on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180.days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ! •" T. k \_Yk l i Date
BUILDING PERMIT PERMIT #
DATE. - 10/7-1/ j99VALUATION 'g � d$'k a+� LOT _ TRACT
JOB SITE
ADDRESS 142-44..5 A �i.x'� IDA@, RUBIO
APN
V _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LA OUiNTA CA 9223
USE OF PERMIT
GVtNNr.,3tA! p F jt.d�lJC ti }
Sou L.F. 4' (a'A},C.i QN WALL - CITY STANDARD
n FT. WALL LL 140,00 t.F
4
Y'. S
��Y�g,,yyi1' mn d' e �yg� u p� O!''P+ 8��,,��..��•�•�ss[e �ypa��t.
s '�•, �
+PERAM VEE Si( MMA
uiw{
c � ��t'}iiil� Fl�a�t 3 A?I✓ 10,1-0(X)- 41&- W S63,00
i , ,
t' < F', .•' .
9ti9
�6 tsi•�I't�'I:A.I:, C;(.1�t`"f'�adLlf".i")jC%N t1�iT) �1.�Pe.AD t"'��%6,,tuC>.`�tii.tiQJ
LESS PRE -PAM FEES
TOTAL VVEN. OVE NOW,
$6,3M
RECEIPT
DATE
BY - "
DATE FINALED
INSPECTOR
• r,.//va.. V
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts r
Forms & Footings
Ducts [
Slab Grade
Return Air I
Steel
Combustion Air t
Roof Deck
Exhaust Fans l
O.K. to Wrap
F.A.U. I
Framing
Compressor [
Insulation
Vents t
.Fireplace P. L.
Grills
Fireplace T.O.
Fans & Controls I
Party Wall Insulation
Condensate Lines ;
Party Wall Firewall
I
Exterior Lath
;
Drywall - Int. Lath
i
t
i
Final I
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel ;
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover [
Equipment Location t
Underground Electric I
Underground Plbg. Test [
Final
Gas Piping
PLUMBING APPROVALS
Gas Test i
Electric Final
Waste Lines
Heater Final ;
Water Piping
Plumbing Final ;
Plumbing Top Out
Equipment Enclosure t
Shower Pans
O.K for Finish Plaster ;
Sewer Lateral
Pool Cover I
Sewer Connection
Encapsulation i
Gas Piping
[
Gas Test
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)
fj, 1_�i -, ', �
A 'At A A&ML
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
im I provements'specified.
For your protection you should,be aware 'that as.".O;wnerl Builder" you are the responsible, party, of record on. such a
permit. Building permits are novrequiiiecl'io be signedby_propetty owners unless they are'person.illy performing -their
own work.. If your work is being.performe-cl'by someone other than yourself, you may protect yourself from possible
liability if that person* applies for the pro . r permit in -his"or her name.
y pee1 .1
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 itiformapion'for your.benefit and.0ratection:
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,;andsuch persons are ;nor licensed as contractors or
, pi' oj
subcontractors, then you may bean .employer.
If you are an employer, you must register with ;t,he'State and,Federal Government as an -employer and you are.subject
to several obligations including State and Federal income: tax wi
thholding, fecerafsociiF'security taxes, worker's
s and-unerh I' compensation contributions.
compensation insurance, disabilityinsurancecost unemployment compen, n
There may be financial. risks for you if you do not carr y*.ou't'these obligation's, and. these risks are especially serious with
respect to workd's compensation insurance.
For more specific information'ibo'ut y6ur obligatio,nI.s'un , derfecleral Law . tcontaci'the Internal Revenue -Service (and, if
you wish, the U.S. Small Business'Admitistration). Fouinore specific information about your obligations under State
Law, contact the Department of Benefit*?aymenti. andtbe 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,,t'hrough't'heir own employees, -without a licensed' con*tracto r of's subcontractor, only under limited
conditions. -
A frequent practice of unlicensed persons pr'of6sini',to be contractors is.to.secure.an "Owrier/Build,er" building
permit,- erroneously, irnpjying.:that ,"the.property ownefis .providing' . his or her
r .own labor. and material personally.
Building . pe . rm*its are not required to be sign ed by property . owners Unless they are performing 'their own work
personally.
Information,a&6u'ilicensed contractors may Abe' ,obtained . by contacting the. Contractors' State License Board in your
community or at 1020 N. Street., Sacramento, California 958.14.
Please complete and return the enclosed -owner-builder',verificatipin form so tffiat,'wetan confirm that you are aware of
these matters. The.building per rhit will not.be issued until:the"verification is returned. -
Very truly yours,
CITY, OF LA QUINTA
DEPT.-& BUILDING AND SAFETY
78-495 Calle Tampico
La Quintit,'CA. 92253
(760) 777-7.012
(760) 777-7011
O7\VNEk'S'SIGNATUkE/DATE
r. PROPERTY ADDRESS
o
PERMIT NUMBER(s)