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0010-208 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter,—, .commencing with Section 7000) of Division 3 of the Business and Ri'of6'ssit3n''Is Code, a_,nd my License is in full force and effect. License # "' Lic. Class Exp. Date Date Signature of Contractor. 7;7 ' 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 (Seco - 7044, Business & Professionals Code). ' ' I•`� , O Ir I am .exempt under Section `�,,B&P.Gt: for this reason e, Date a`�fr t' � �% ,� Signature of Owner "k (. 01 tr f WORKER'S COMPENSATION DyECL`ARA LION . ' 4, j'4 d 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: Carver Policy No. (This section need not be completed if the permit valuation is for.$100.00 or less). (; (, certify that in the performance of the .wo--r0or 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.-Galifornia, and agree that if I should become subject to the workers' compensatf'bn provisions of Section 3700.of the Labor Code, I shall forthwith comply wit '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, 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. correct. I agree,to comply with all'City, and construction, and hereby Iauthorize represe the above-mentioned property fo'r inspection (Owne that the above information is laws relating to the building . -s of.this City to enter upon , .N,. BUILDING PERMIT PERMT# . DATE VALUATION LOT TRACT f), ltrxwn 5 JOB SITE APN ADDRESS OWNER CONTRACTOR/DESIGNER/EN (NEER C 31AP 4 USE OF PERMIT f'ING, r MMIALTED COST OF CONSTRX111=019 2,5W.00 CONSTRUCTION E 101-000-43 8a000 LtT� O3'f B-110°I<"V., e:>ONVI MUCTIOW I �'`� $54.00 SIS PRE.WMWO' N, $0.00 wr vu, nnffrEEE iii; .,10 W $04,00 RECEIPT DATE �, BY DATE FINALED INSPECTOR INSPECTION RECORD ' OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Racks 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 Wali Firewall Extehoe Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS -SPAS steel Set BacksElectric Footings 5 Bond Beam gg �( 3 — ®a �1'% Bond Main Drain Approval to Cover Equipment Location Underground Electric Underground Pibg. 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 Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: l MetroScan /Riverside (CA) Parcel : 773 291025 Pos Int - RefAPN : 000 000-000 Owner : Pfannkuche Nancy L Land : '$25,463 COOwneY Struct : $27,500 Site : 52523 Avenida Ramirez La Quinta 92253 Other t' Mail : 74873 Merle Dr Palm.Desert Ca 92260 Totdl : $52,963. . Xfered • :06/10/1998' Doc # .:237228 Exempt Price ". : $52,000 Deed : Grant Deed Type . ,LOanAmt : , Loan _ % Imprvd :52 Lender • IntTyp :. % Owned : 100 vestTyp Tax Area : 20-017 Use : ROI Res, Single Family Residences 99-00 Tax /:'$1,019.16 Plat :,18 Map Grid : 879 E1 Census : Tract :451.04 Block : 7 OwnerPh S : ; T R Q Tenant Ph Bedrms : 3 . Stories : 1. Acres :.30 Year Built : 1977 BthFull `. 1 Fireplace No LotSgFt J3,068 Street Type : Paved Bth3Qt J 1 Pool : No Bldg SF :1,204 Waterfront BthHalf ; RmAddtns • : Yes AddOnSF Gas Service : None CntlHt :,Yes AddPkgTyp, GarSgFt : 483 Water Source : Developed CntlAIC : Yes Roof Type : Composition Gar Type Detached ' Sewer Type : None Agri Preserve 773�9�� r. N. a 6,W-O/r 020-100 POR. N //2 SEC. /2 r6 R6E , 020 -Or/ 020-/j/ .. • OPO -019 020-09/ - - - 1 020 -Oar "LLE - t ;•z�`""' ENSENADA — S O/ A •• ., .• y wv r , ,+ - lea /a0• � .u. y • /I t FR + 22 Q /_- 22 0 ®/ _ ,e YP ®� / 22 '2/ © ® P 2/ O @Z o.v 21 (2) ®2 P/ ® 0Z 2/p 02 I + POO ®S �' 20®@5 2 , 20 © ®J (O, 20 © © ! n Q. /9 O 1 Q /9O ®oN-09. /9® 04 4. /9 6 ®S O IB 6 0 3 ®! ge T®l V$® ® S O E • c 1! J I " „ ^� v �, � /6 0 ®7 /6 /6® ® 7 /6® ® 1 /6'e ®7 A d /S.O9 ®B /S ®9 /!� B /S ©a. /S ® ®B . C __ _ • � $ O r! ° , C oro -as/ O W H ® e•s9 W ,N O uey9 _s. ; r./� ® ® g ; p ® ®9 W /4 // /! ® Gam/ Q /3 O ®/O /! // ®/O ♦ /So /O W • /2 /�' ®//� /P 0 ®// /P ® g 9 � I' i /P ®// r I � /Y ® C"j // I >• ZEE �a' GALLE —1 ... `• h= NOCALES —1 `-„•” Santo Ca7ma6/o A/ tb/s La O/mlo. Unit Na /6 NB 18/99 4 No /O Mil /8/70 - 32 • • • Na // MB /B/73 .a5 5sriv's aw w rn M29 a The Information Provided Is Deemed Reliable, But Is Not Guaranteed. ` x 773�9�� r. N. a 6,W-O/r 020-100 POR. N //2 SEC. /2 r6 R6E , 020 -Or/ 020-/j/ .. • OPO -019 020-09/ - - - 1 020 -Oar "LLE - t ;•z�`""' ENSENADA — S O/ A •• ., .• y wv r , ,+ - lea /a0• � .u. y • /I t FR + 22 Q /_- 22 0 ®/ _ ,e YP ®� / 22 '2/ © ® P 2/ O @Z o.v 21 (2) ®2 P/ ® 0Z 2/p 02 I + POO ®S �' 20®@5 2 , 20 © ®J (O, 20 © © ! n Q. /9 O 1 Q /9O ®oN-09. /9® 04 4. /9 6 ®S O IB 6 0 3 ®! ge T®l V$® ® S O E • c 1! J I " „ ^� v �, � /6 0 ®7 /6 /6® ® 7 /6® ® 1 /6'e ®7 A d /S.O9 ®B /S ®9 /!� B /S ©a. /S ® ®B . C __ _ • � $ O r! ° , C oro -as/ O W H ® e•s9 W ,N O uey9 _s. ; r./� ® ® g ; p ® ®9 W /4 // /! ® Gam/ Q /3 O ®/O /! // ®/O ♦ /So /O W • /2 /�' ®//� /P 0 ®// /P ® g 9 � I' i /P ®// r I � /Y ® C"j // I >• ZEE �a' GALLE —1 ... `• h= NOCALES —1 `-„•” Santo Ca7ma6/o A/ tb/s La O/mlo. Unit Na /6 NB 18/99 4 No /O Mil /8/70 - 32 • • • Na // MB /B/73 .a5 5sriv's aw w rn M29 a The Information Provided Is Deemed Reliable, But Is Not Guaranteed. ` 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 not required to be signed by property owners unless they are personally 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 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 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 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 not 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). For more 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, 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 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 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 QVINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico FAK0 77-70 FAX: 760) 77-7,ZO11 'S SIGNATURE/GATE &'g��4WAWL4q W o ©I n PERMIT NUMBER(s)