0402-153 (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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( jI�am exempt under Section B&P.C. for this -reason
Date :.i- 4- f</ 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).
( u) 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
subjectto the workers' compensation provisions of Section 3700. of the Labor
Code I , shall forthwith comply with those provisionsI-,,
Date: Applicant�'
T -,•_,v-
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/AgeriDate 13
J
BUILDING,P'E WIT PERMIT #
DATE VALUATION ' `- LOT. TRACT
i3�19.3r&,�1C l:�:1 °5
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JOB SITE p dtapev1 A •��r[p-s
ADDRESS :i �,—;1�`se9 n"\fit%M"31 +t drA aVA4ii lj. t.+
APN
OWNER •
CONTRACTOR / DESIGNER / ENGINEER
OSCAR _MARTK U-,,
T311.011-JER
3
LA Q1104TA CA. 92253
i ! 03j,",
USE OF PERMIT
140 11F. 5' rd,.RDEN P A1..L, 5.7 L.TK 5' O.ARDE111 WA L1, 301-H CITY
STANTa.d'aA;D ` OBE BUILT ALOII O REAR, AND SIDE Y':ARLD P/L t,14D
113vCIDSE FRCYHT C:OUIRTYARL). 2001 rBC.
4 17. WAL , H0100 LF
5 IrT. 'WALL 57.00 LF
ES'•1TMX!KfJ COST OPCONMUMON
4,734.05
P XR.IVtrr bf"L�s'. Sit IV
CONSTRUCTION FEE 101-000-4,18-000 $7 ,011
r
FIr6 x'013-Tf"TA C.r . 1' RUC'T101T AND PLS. ' i� M.0
LI Z: SS PPY,-PAID h'h7i�?
17
O.OD
SEB 13 2004 Ar=.Ia1�.�r1�;:��rlv0;..�
CITY OF LA QU 1,A
FINANCE DEPT. /
V:
RECEIPT
DATE (/
BY-
�--
DATE FINAL jD �I
INSPEC R
.1111. ii Y
- -
/ , c�
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
Shower 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 VoRage Wiring
Fixtures -
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
V C
OWNER / BUILDER INFORMATION
Dear Property Owner:
An application fora 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 not<required to be signed by property owners'unless they:are`personallyperforming. their
own work. If -your work -is -being performe&by someone other than yourself, -you may protect yourself from possible
liability if that.person-applies•for the prop .r.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: TFtey, are also required by law. to put their,license:nurnber 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 informaiion for your,beriefir and protection:
If you employ. or otherwise.:engage,''any persons other than' your immediate -family, and the work (including materials
and other costs) -is,$200.66 or more for -the • entire project, and such persons are not. licensed as contractors or.
subcontractors, then you may bean 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.insuranc. costs and unemployment compensation contributions.
There may be financial risks for you if you do not earry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about.your obligations und'e'r Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small BusinessAdmins'tration):• Formore`specifrc�information'aboutyour obligations under Scare
Law., contact the Department of Bene-fit.Paymerits and"the Division of IndustrialAccidents.
If the structure is intended for sale,:properiy owners; who are not, licensed contractors aie allowed to perform their
work personally or through`. their own employees .without a licensed contracto �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 that the-property'ownei ls,providirig his ;or her own.labor and material personally.
Building permits are not' require_ d 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. The building.perrhit will nor be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78495 Calle Tampico
La Quinta, CA 92253.
(760) 777-7012
FAX (760) 777-7011
,71V 1� •
PROPERTY ADDRESS
PERMIT NUMBER(s)
CURBLM
5