0401-287 (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:
(f�) 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 0
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.
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
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 `
i
BUILDING PERMIT PERMIT#
DATE 01121/200 VALUATION $566.00 LOT TRACT
JOB SITE
APN
ADDRESS 51-305 AAI IiDA 11" MZ
- -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Diu M13"Mm 1-lOWA
51-305 AVFNMA P_*&REZ
LA Q1'.i' NTA. CA 92253
USE OF PERMIT
OF14MAL BUILDrAG
6 L. F. 6' GARDEN WALL, 26 L.P. 4'GARDEN 'SMALL, BOTH CITY
STANDARD
6 FT. WALL 6.00 L
4 I T. WALL 15.00 LF
EgaKATKD COS' OF OORSTRUMOP
566.00
P W , T FXE aIva"ly
CONSTRUCTION M, 101-000-418-000 $19.00
-� ::10
PfJANQ 2 0 2004
CITY OF LA QUINTA
FINAMCE DEPT. _
MB-Tc7TAL CON17FR.U(,lTOA1 AND PLAX CIDICM
$17,00
IMS PRE -PAID FERS
$0.010
Tdi371AL Y`.KiZ1' T171MES ME .NOW
$17.00
RECEIPT
DATE
BY
DAT FINAL
INSPEC
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 Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Ahower 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:
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
permit. Building permits.are nor required to be signed by propertyowners unless they arrpersonally 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 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 variuus:trades that you plan to subcontract, you should be
aware of the following'iinformation for.your benefit and protection:
If you employ or otherwise engage.any persons otherthan 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 licensedas 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, feder5;l� 'social"" security taxes, worker's
compensation insurance, disability insurance costs and�une nployment compensation contributions.
There may be financial risks'for you'if you do not carry: out these obligations, and these risks are especially serious 7.i
respect to worker's compensation insurance.
For more specific information about your: obligations under.Federal Law, contact the Iniernal Revenue Service (and, if
you wish, the U.S.' Small Business"Adminstration)._ For more specific in 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, property owners who are not 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
permit, erroneously implying ihaf.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 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. Thebuilding 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: (760) 777-7011
12Q 1S�AAV>
OWNER'S SIGN RE/DATE
PROPERTY ADDRESS
Dllol - ;?g 7
PERMIT NUMBER(s)