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0301-401 (BLCK)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: ( ) 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 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 provisions. Date: 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 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 ' .BUILDING PERMIT PERMIT(n►#nn�om��@@��((��gy• DATE /i v ,` VALUATION LOT TRACT JOB SITE APN ADDRESSa/ 1.��i�! kUE��C� W OWNER �^ CONTRACTOR/DESIGNER/EN (NEER 1 AI10A & MAN RAJAREZ t'?WI M. BC1.iUYER 52.950 AV12,41DA R,.6J'45IO I.A Qi1MA CA 9225:3 USE OF PERMIT ffil3:NIMAL B'UI'LDING 129 3L, K 5° 0AJ* .)E1J WALL -CITY STA)4EIA.RD S FT. W.All 3.23.0D LF ESTIMATED C09J* 03+ CONSTRITC-MON 2,r yrtao MfAff€'IR S "R`Y' Ci NTPRUCT(ON FEZ 101-400-418-000 $34.00 S'OB-iU`rAL. CO.trS'TF. UCTIOleS -Al4D 1?,. "-CMCK $54.00 3 r,. N!.PAM F. so.00 :a.'Cy PE. :E+'.1QV; XXT.E .P4(fQV JAN 2 9 2003 CITY OF LA OUINTA FINANCE DEPT. RECEIPT DATE j ` E71 Yr, DATE FINALED INSPECTOR E 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 8 Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs — - O Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Electric Final Waste Lines • Heater Final Water Pipingi 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 COMMENTS: �J `fes Final Utility Notice (Gas) y ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fbctures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) 4..'.9;x•1':: IL. �i» 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 /Bu ilde.r" you are the responsible party of record on such a permit. Building permits are not required to,bessig ted by property owners unless they are,personally performing their o" -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 ii•his or her name. Contractors are required.by law to,belicensed 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'iicensed as contractors or subcontractors, then you -may be in 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.no 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).4ourno- e,specific information about your obligations under State Law, contact the Department of Benefit Payments `and the Division of Industrial Accidents: If the structure is intended for sale, pioperty owners who are noir"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 unlice ns'ed<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 notrequiredto 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 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 92253 (760)'777-7012 FAX:Z70) 777-7011 O ER'S SIGNATURE/DATE >y5�4, Cr PROPERTY ADD` PERMIT NUMBER(s) A 'U. 4:, i p , F LOCATE ALL E"UILDINGS,ON'-PLOT•�PL4N REMEMBER TO INCLUDE ANY PATIO'.S`"OR ADDITIONS t �iTY OF BUILDING APP FOR CQ . DATE _-1LG1"r 1 P11-l1�lTe DEPT. 1 A Til 1 -The illustrated minim.urn setbaci s must be observed wniie designing DfOD052d structures or additions. Patio areas May 20'Minimum r (Rear) encroach -into setbacks provided no fire dancers are present.' T° New••sl,ructur2s must ooserve side yard setbacks of 10 feet Maximum Lot Cn Cr1e::,S1C2 anc 5 "te;�,t on the other'side. o-• S' Min. Coverage may 5' Minimum not be more than d00,1a. 10' (New) 1 20' .Minimum I (Front) T V 1 e (� NAME: �` .S U `1/•t �vl l 1/ Z AOORESS: ,� 2' a A V C9 Ia PHONE: PROjEC LOCA ION: c•ti,, .,l .f=_r•holla r)an. nnnl'of Cor.jrIUniIV I�pvgic;pTanl 't-3-08 P.O. BOX 1504 APPLICATION ONLY Buildingff 7&105 CALLE ESTADO Address V e R c<<ot o LA QUINTA, CALIFORNIA 92253 Owner /� Mailing B ILDING: TYPE CONST. OCC. GRP. .K .C7�1 }Address � n �% > . _ q � — � O ( o /t/�o S lT A.P. Number f City Zip Tel. ld i �� ( , Legal Description f �. L It iso S Contractor Project Description ` Address City Zip Tel.. - - - State Lic. City & Classif. Lic. # Sq. Ft. No. No. Dw. Arch., Engr., Size Stories Units Designer New O Add O Alter ❑ Repair ❑ Demolition ❑ r . Address Tel. wli L4 310 City Zip State 0j(,1 Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. SIGNATURE DATE - OWNER -BUILDER DECLARATION Estimated Valuation I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also - - requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT - AMOUNT the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit Plan Chk. Dep. subjects the applicant to a civil penalty of not more than five hundred dollars ($500). l7 I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal. do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.` Professions Code: The Contractor's License Law does not apply to an owner or property who builds or improves thereon and who does such work himself or through his own employees, Mech. Provided that such improvements are not intended or offered for sale. If, however, the building ^-• orimprovement is sold within one year of completion, the owner -builder will have the burden - 1 ` « .11 } `.;�• ,� 1 .� {�`\ of proving that he did not build or improve for the purpose of sale.) Electrical '•1 I 1 I, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing struct the project. (Sec. 7044, Business and Professions, Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for $,M,I. ' '� '' •� ,('' . such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) , Grading 17 1 am exempt under Sec. B. & P.C. for this reason Driveway Enc. Date Owner Infrastructure WORKERS' COMPENSATION DECLARATION w I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) - Policy No. Company - - O Copyis filed with the city. ❑ Certified copy is hereby furnished. TOTAL CERTIFICATE OF EXEMPTION FROM REMARKS WO R K ERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation or less.) rrr 1 certify that in the performance of lhp 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. - Date Owner NOTICE. TO APPLICANT: If. after making this Certificate of Exemption you should become ZONE: BY:— subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances: comply with such provisions or this permit shall be deemed revoked. Front Setback from Center Line Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line - Lender's Name - Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out, signed and validated, and is subject to - expiration if work thereunder is suspended for 180 days. , I certify that I have read this application and state that the above information is correct. Issued by: Date Permit - I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter the above- mentioned property for inspection purposes. Validated by: ' Signature of applicant Date Mailing Address Validation: • ` City, State, Zip FINANCE X ,jj �2M3 a X ,jj �2M3