0203-201 (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
f. 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:Ifor this reason
Date : 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'
4
:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs /C'„'
Electric Bond
_ _
Footings r `
Main Drain
Bond Beam /_ _.�
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final — Q
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
OWNER%BUILDER INFORMATION
Dear.Property Owner:
An application for a.building permit -has been',submitted,inyour`name lisiing yourself as the builder of the property
improvements specified.
E
Foryour.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`b roperty owners unless -they are -personally performing their
own work. If your work is- being,performed.by someone ocher than yourself y&i"may' protect yourself from possible
liability if that person applies fo'r`the proper permit rn his -or her name c
Contractors are required by,;law to be licensed and bonded.by the Staie,of California and to have a business license
from the Cit ot'Coun"„The are also ie uue`d by',law to put their license 'number on all permits which the
Y` Y Y required, P P Y
apply. h...
If you,plan to do, your own work :with the exception of various'trades that Ou plan "to `subcontract, you should be
aware of the following information-foi-your b6h fit and protection:: '
If you employ or otherwise egage any persons ocher than your immediae.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, theiiyou-ritay`be an employee l.,
If you are an employer, you:musregister with"fhe'Scate and Federal Government'as an employer and you are subject
to several obligations including State anclTederal::,income tax withholding federal social security taxes, worker's
compensation insurance,,disability insurance costs`and.unemploymentcompensation contributions.
There may be -financial tisks.for you if you,do not carry out these obligations and these risks are especially serious with
respect to worker 's•compensitton insurance.
For more specific inform ation.about.your,obligations undei.Federal1aw, contact the Inteinal Revenue Service (and, if
you wish, the U S Small Business Adminstration)..For more specific information aboutyour: obligations under State
Law, contact the Department of Benefit Payments and° lieDivision of:Industrial Accidents.
If the structure is intended for sale,' properly owners who are; not licensed contactors are allowed to perform their
work personally or through;.their'own employees, without a liceiised contriiq r'or subcontractor, only under limited
conditions.
A frequentpractice;of unlicensed;persons,'professing to be�contractorsts to secure an "Owner/ Builder" building
permit erroneously :implying that ;the property owner rs;;provrcling hiss of her�;own ,labor -and material personally.
Building permits are not required to be signed by property owners unless they:- ;wperforming their own work
personally.
Information about lice nsed`contractors may be obtained bycontaeting the; Contractors` State License Board in your
community or at 1020 N Street, Saeiamento,.California,95814'.
Please complete. and return the enclosed owner-buildevverifrcaiion form so that we can confirm that you are aware of
these matters; The buildrnggpermitioill not be issued untifi' a 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
F (760)777-7011
"ER'S SIGNATURE /DATE
_5- y O 0(—'.S` 44,-C A4 /iii 2 C Z 4,4
r`=
PROPERTY ADDRESS;;, '
PER�NtMBER(s)
0.....1 LA QUINTA
�','NG & SAFM DEPT.
-PROVED
FOR CONSTRUCTION
I
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