0311-233 (RR)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
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:
(91 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 r. '+ Signature of Owner ��:• .., ..� _• � ..
WORKER'S COMPENSATION DECLARATION y�
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 whichihis permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for theperformance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No. .
J (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: �` r'., -//'. : Applicant
1 ' '(
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 Libor Code, interest and attorney's fees.
I
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
nh & 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) Date
.BUIDING PERMIT PERMIT#
DATE VALUATION" ���•� LOT TRACT
JOB SITE
ADDRESS 52-940 AVENEM f"ZUZO
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
Bld/W MALONEY
OWNER - BTxT1 D R.
52-900 AV'ENMA RUD10
LA QT)DTTA, CA 92253
c�-
USE OF PERMIT
OEWRAL B1J1l.DiA O
R&ROOF WITH CLASS A SHINOLE, WI.A't'f ER K.
'V'0>aLUAT1014 1,,3�D.�t� LS
TL:P'7f1<[VIATW COST OF C;ONS'TRUC7TIO •T
PRR'WT 1EE 9UNMAC Y
MIROOF FEE 141.000-4118-000
b 1"
D
NOV 2 4 2003
Cir
MM-TOPAY, COI , TR.UMI171dA[vtA/MAN C.ca»n..K
$30.00
LESS PRE -PAD) FMS
$0,00
YOTA 'e FERMCr P 05 'DUff' NOW
1130.00
RECEIPT
DATE/
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings I
Ducts
Slab Grade i
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing I
Compressor
Insulation I
Vents
Fireplace P.L. {
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath
Drywall - Int. Lath I
I
I
I
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs i
Electric Bond
Footings I
Main Drain
Bond Beam i
Approval to Cover
i
Equipment Location
t
Underground Electric
I
Underground Plbg. Test
Final i
Gas Piping
PLUMBING APPROVALS
1
Gas Test
Electric Final
Waste Lines i
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans I
OX for Finish Plaster,,.,
Sewer Lateral I
Pool Cover
Sewer Connection 1
Encapsulation
Gas Piping }
Gas Test )
Appliances 1
1
Final
'
1
Final 1
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Vobge Wiring
Furfures
Main Service i
Sub Panels 1
Exterior Receptacles-
G.F.I. }
Smoke Detectors I
Temp. Use of Power
I
}
Final i
Utility Notice (Perm)
COMMENTS:.:;
/-
� •
2." V
,
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
peimit. Building permits are not required to. be signed by property owners,,unleis they are personally performing their
own work. If your work'is beingperfoimed 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 or County. They are also required by-law to put their license-num'ber on all permits for which they
apply.
If you plan to do your own work;:wiih the exception of various trades i --hat 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 otherrtthan.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 Itax with''olding ;federal social security taxes, worker's
compensation insurance, disabiliiy insurance costs and.unemployment compensation contributions.
There may be financial risks for you.if you do not carry our these obligations, and these risks•are especially serious with
respect to worker's compensation insurance. e
For more specific information about. -your obligations under.Federal Law, contact -the Internal Revenue Service (and, if
you wish, the.U..S. Small Business Admiristrauod . For more specific information aboutyour obligations under State
Law, contact the Department of Be'nefitPayments and the Division of Industrial Accidents.
If the structure is intended for sale, :property owners who,.are: riot 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 unlicerised.persom 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 iperforming their own work
personally.
Information about licensed contractors may be,o.btatned°;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-builderverificatiori'form, so that we;:can confirm that you are aware of
these matters. The building permitwill 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 Qu nta, CA 92253
(760)777-7012
FAX: (760) 777-7011
OWNER'S SIGNATURE/DATE
PROPERTY ADDRESS
cl).//l -
PERMIT NUMBER(s)