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0402-014 (RR)LICENSED CONTRACT6113 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 = f Signature of Owner ,., i "• �._. ~ �,_ .. 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: pplicant Warning: Failure to secure Workers' Compensation coverage isunlawful 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)"-, '' ' �""-.1­—Date'-,"T ` t BUILDING PERMIT PERMIT# 0402-0.14 DATE _ VALUATION $7,2905jo LOT i TRACT JOB SITE ADDRESS 33-730 �.�lKl'VI1 A RA.1�1:SIt%; i; APN OWNER CONTRACTOR / DESIGNER / EN (NEER 'CSU C'I�.c OVAM, Z RU ICER 53-730 AVENMAI'tA1Vi:C1Z:EZ 1AQ[YIN't'A CA 92253 t j L;T3LSi USE OF PERMIT C3ENM AI, RG' Q Dd"1`8C - RE-ROCIFICOMPOSITP SMINGL&q/CI_U%9 "A" MATERIALS ONLY. R ROCIF J,290.00 L4 EST ITER COST OF OOI^NSYRTJMOW 7,290.00 I'1a F�"T I3 917WWARY IMOOF RM 10I 000.1118.000 �i3®.fiD FEB 0 3 2004 CITY OF ate. QUINTA FIa�ANCE DEPT. SUB -TOTAL COMMUC110N AND PLAN (a -CK $30.00 LESS PRE -PAID FRES $0,00 TCf'.I'A.i. 3'Y<k?1'"r:r +m TDZI1f I4mmi 00 RECEIPT DATE BY '-s"�^ ? DAT F ALfjl INSPE 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 DrywalI-- nt. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS 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 COMMENTS: Final Utility Notice (Gas) - ELECTRICAL APPROVALS • Temp. Power Pole Underground Conduit Rough Wiring Law Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I: Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) e. OWNER/ BUILDER `INFORMATION. Dear Property Owner: An application for a building permit has been submirtedin your. name listing yourself as.the builder -of the property improvements specified. For your protection you should:be aware that as" Qwner/.Bu lder'.'. you are theresponsible party of record on such a permit. Building. permits are not tegired to be signed byproperty owners unless.they arerpersonallyperforming 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 oi;her:narrie.. Contractors are required by law to be licensed and ibdii&d by the State.of Cal:ifornia:'and to have a business license from the City or County. They at 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 otherwiseengage any persons other than'your immediate. family, and the work (including materials and other costs) is X200':00 .or more for the entire.prcjectj'a'nd'such persons are not licensed as contractors or subcontractors, then you maybe 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- andFederal income tax withholding federal social security taxes, worker's compensation insurance; disability insurance costs andiinemploymenccorppensation contributions. There may be financial risks for you if you do not carryout these. obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations undet�Fecldal'Law„contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more"specific information about your obligations under Scare Law, contact the Departmenf of Benefit Payments and_tlie.`Dn+ision of Industrial' Accidents. If the structure is intendedfor sale, property owners, who are nor 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 prope"rry 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 K Street, -Sacramento, California 958.14. Please complete and return the. endosed owner ;builder;verifrcaton'form so.that we.can confirm.that you are aware of these matters. The building. permirwill not be issued until -the ve ifrcation.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 ' OWNER'S SIGNATURE/D 53 --?30 ri-Z A � � `i 2 Z- �" 3 PROPERTY ADDRESS': PERMIT NUMBER(sY'