0308-160 (RER)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:
`�Q 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).
Q.,. I am exempt under Section B&P.,C. for this reason
Date Signature of Owner 112.41.4 -IN
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,
11th -'all 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 provisi,o`ns.
Date: Applicant 40��1nT l o a•., ojy •r_
. _ti1 _
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)ll�etf��lrir,W.^ t n�ntn0 v"Z Date
PERMIT#
- BUILDING PERMIT
DATE vALUATION'LOT $ rTRACT
. 4... ~' 10 :RIX, 2, 2
w
JOB SITE ^`t
ADDRESS 53-715 AWJ.1TVA DEL1M9.RFZ
APN
774-121-022
OWNER
CONTRACTOR / DESIGNER / EN (NEER
ROOKU0I-Y NANDM
Owlc1�"i2f13LTILDR.
53.715 .AVEI+ITDA RAMI Z
LA t7M-'1"A CA 92253
(, }
USE OF PERMIT
ADDITIO1dIVU401 EL - 535 EQ.IP17. GARAL1IZ &I£NTRY lDUITIONr
REMODEL RE1°r1$3dLT)OOR, 2001 CODES.
O.ARAWCARPORT 426.00 3F
PORCFIOPATTO T09.60 SF
MV WATM) CCW ON, C`i7lNrai Ki'L 6113
9,74319,30
PLAN CHWK FRE 101-000.419.31$ Mo..
CONSTRUCTIO14 FEE 101-00"18-000
L�L�C'�R1C�h1, FEE 101-000-420-000 $2.70 .
STIaTNIGi MOTION FEE - RE.SID 101.400.24.1-000
SUB -1CnAT, f"01J9MU('r10A A14D PLM C':l[$F.M
$21933
LM PRE-PAYD FSE
$0.00
TOTALS FJM S 1DUF_ Now
$21.3.73
OCT 16 2003
CITY OF LA QUINTA
. .
FINANCE DEPT
't
RECEIPT
DATE. i `' ,l' �1
BY.s
DATE FINALED
INSPECTOR.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs Q—d L
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
C`v
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City ®f la ,.� Quin
Bwlding' 8 Safety Division
P�4� Box 1504, 78-495:.Catle Tampico
La.Qwnta, CA°92253 • (760) 7774012
_ Building.:Permit.;Appltcation and Tracking Sheet
Permit #
Project Address: 53 - 7 l�. wE. 4
Owner's Name:
un Qe z
Address:
A. P. Number:
Legal Description:�.
Contractor:'
.-
Cih.'ST. Zip: '
ilTelephone: „•"—�
Address:
Project Description:
City? ST, Zip:
tL
Telephone:
.- •; . N':
State Lic. #:
City Lic._ #:
5-� z2o (�3L z
Arch.. Engr., Designer:.
Address:
City. ST. Zip: '
Telephone:..
��--:.. ...,'^ -
;-j .,
Construction Type: Occupan
State Lic. #:
Project type (circle one): New Add'n Iter epair Demo
Name of Contact Person:
'Sq. Ft.:
#.Stories: # Units:
Telephone # of Contact -Person- _ !S
stimated Value of Proje
APPLICANT: DO NOT WRITE $ELOWTHIS LINE
#
Submittal
Req'd
Recd
=TRACTKING
PERMIT FEES
Plan Sets
p2,
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed read] .for corrections
Plan -Check Deposit
Truss Cales
a
Called'Coniact Personl
Plan Check Balance a
Energy Cafes.
' Plans picked up
9/a s
Construction • ,
Flood plain plan
Plans'resobmitted yr(;
Mechanical
Grading plan
Review ready for eorrectio issue
!�
Electrical •
Subcontactor List -
-Called ContachPerson
Plumbing
Grant Deed
Plans picked up
S.M.I. o
H.O.A., Approval
Plans resubmitted
Grading
M HOUSE:-
"'"' Review, ready for correction issue
Io
eveloper Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. APpr
Date of permit issue
School Fees
Total Permit Fees
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 bylaw 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 bylaw to put their- license num6er!-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 information for your'benefirand,protec' non:
If you employ or otherwise engage any persons other than your irnmediaie 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'Fedeial income, -tax withholding; federal' social security taxes, worker's
compensation insurance, disability insurance Icosts and.unempl`oyment 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.
a1
For more specific information about your obligations under•Federal Law; contact the'InternaMevenue Service (and, if
you wish, the'U.S. Small Business Adminstiation). For�more specific information about your obligations under State
Law, contact the Department of Benefit•Payrrients and the Division of Industrial Aeeidents.
If the structure is intended for,sale, property, owners_ who: are; not' licens'e'd contractors are allowed to perform their
work personally or through'thetr own employees,.without a licensed contractor'or'subcontractor, only under limited
conditions.
A frequent practice of'unlicensed persons,professing Lobe contractors is to secure an "Owner/ Builder" building
permit,, erroneously rnnplying= that the -property ow
'ner is providing his or her own labor and, material personally.
Building" permits are not required to . be` signed --by, property owners unless` tl ey are performing their own work
personally.
Information about licensed contractors m'ay 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 enc losedowner-builderverification form so'that we.can confirm that you are aware of
these matters. The building Permit 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
f% J. // " 4. �."
OWNER'S -SIGNATURE /DATE