0109-105 (PLBG)U)
l'—
CNN U)
W
O �
W r—
O Z r -
ZD 0. 0
H�
J
W LU
CLZ
co
N
ON
U0)
d Q
Z
Lo aCr
0
mQU
OU
� 0)
`t Z
ob:D
O
Q
J
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
P_rofrelionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7+5119 CA2
L,Date pSignature 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 & Profess'onals 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 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 re.gijirerf 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.
ST.47`R? AMD 1157Y291-01
(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; l shall forthwith comply Applicant J' With. those provisions.
—
,Date: r � �•.n';.� .�r !
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1: Each person upon whose behalf this application is made & each person at "
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold .harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the"above-mentioned property for inspection purposes.
Signature (Owner/Agentt)' Date;
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
rid -150 CALIXL CAM,
IRI -035 CADMOIT;M TWA(% CA 92201
1-A x1114 ' . CA 92253
PALM..DWERT CA 92261
L2Lft 342
USE OF PERMIT
PL U1BIWO
:53?.b'8HwI . up wune 1`AeCfh:.f3SmC7mSNewr
�J
VALUA.T)IY$ Z350.00 US
bihol lm= C40STOF CONSMJSION
2,3530U
W6&I'Y12R 91RRMRY w
P3s:.tlMM110 FES, - SEWER 101 a 000,419"MO MOD
0 2001
CITY OF LA QUINTA
FINANCE DEPT.
;3111:1d`iC'rA.lLC, -,W CTTON1;; a�iiPI.. 2d JEC71,
M,00
L1..i�2 PRU—MD YENS
$0.001
'd'�OvM ,JCA .S'��.T.ai�.1A,�y�.pr�a'4a�RJ��.Ltl ��YB
�BM75CrleV
RECEIPT
DATE `i
BY
Ii
DAT ALE
o2 d
INSPECTOR
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
t
Final
Final
SLOCKWALL 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
I Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection 9 / /� ( S�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
i 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
1
I
Final
Utility Notice (Perm)
COMMENTS:
COACHELLA VALLEY WATER DISTRICT
RECEIPT DETAIL
40 60
Received From:0
t j
%CASH
Dater.'
Address: / /' --J • C, /
i'i ;��
T ( i. i!
ii•' C/ . .. �` fi
Account No. !r'/° �i�•?6 11 " /'
C" i Lot(s)
Tract
Service Address
G.A. Code
JI
❑ Meter(s)
$
`�
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ Detector Check(s)
❑ Meter Surcharge
Et/Sanitation Capacity Charge
_
1
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
r Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL
Remarks:
+�
❑Odpy to:
Ea
'"%'/�dr
/ �nrr1
:: t:r;
rt
Water Service
i;+t•;. r....,
Cashier
Cash
Check
Money
Order
'.r.•. -r'�
a;:+,.�
CVWD=438(11189)
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICo
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(7'60) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
AAV NOTICE TO FRUERTY OWNER
Dear Property Owner.
An. application for a building permit has been submitted ,iii your name listing yourself as the builder of the .property
impmvements specified at -79 /<_6 /1 -L
We are providing you with an Owner -Builder Acknowledgment and Information Verification.Form to make you aware.of your
responsibilities and possible risk you may incur by having this. permit. issued in your name as the
Owner -Builder. We will not issue a building -permit until you -have read, initialed your understanding of each'pravision,
signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this:notice
unless you, the property owner, obtain the prior approval of the permitting authority.
OVA'S ACIQgO.NV,LEI) iE A,ND`VERiCA` ION OE IIWORM, WN
DMECUONS. Read and initial each statement below ie`stgnify you understand er-verify this information. .
_\J I. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as
an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my. property -
Ai 2. I understand building permits are not required to be signed by property owners unless they are responsible for the
construction and are not hiring a licensed Contractor to assume this responsibility.
J�L3. I understand as an "Owner -Builder" I am the responsi6le.party of record on the permit. I understand that I may protect
myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
J J 6. I understand if I am considered an "employer" under state and federal taw, I must register with the state and federal
government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand any failure to abide by these laws may subject me to serious financial
risk.
30 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
structures cannot .legally build them with the .intent to offer them for sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
r-
� 8. I understand as an Owner -guilder if I sell the property for which this permit is issued, I may be held liable for any
financial or. personal. 4.uries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
J� 9. I understand I may obtain more information regarding my obligations as an "employer" from the internal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
�J 10. I am aware of and consent to an.Owner-Builder building permit applied for in my name, and understand that I am the
party legally and financially responsible for proposed construction activity at the following address:
7fs/eb e ell/ ,/N - - ......
�I. Ll agree that,. as the party legally and financially responsible for this proposed construction activity,.I will abide by all
applicable liws and requirements that govern Owner -Builders as well as employers.
A 12.1 agree to notify the issuer of this. form immediately of any additions, deletions, or changes to 8ny of the information I
have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license'
oard
the Contractors' State License Bmay be unable to assist you with any finandalloss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be ini6vil court- It is also
important for you to: understand that if an -unlicensed Contractor or employee of that individual or firm is injured while working
on your property; you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors,
you will be responsible for verifying whether or not those Contractors are properly licensed and the status of thein- w0l-kers'
compensation insurance voverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuing, the.p emit. Note: A copy of dw property owner's dzlv4r'SJtcerasef form nota MN or
other verification acceptable to the agency is required to be presented when the permit is. issued to verify the property
owner's signature.
Signature of property owner Date:
Note: The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNEWS BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize
the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain ani Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of PLuthorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy. Note: A copy of the owner's driver's license, foray notarization, or other verification
acceptable. to the agency is required to be presented when the permit is issued to verify the property owner's signature..
Property Owner's Signature: Date:
CITY OF LA QUINTA'SUB-CONTRA TOR LIST
JOB ADDRESS PERMIT NUMBER OWNER. BUILDER
This form shall be pposted on the job with the By ild' c "o Card- at all times in a conspicuous place. Only persons appe ring on this list or their employees are authorized to worl
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidanc(
of building permit. For each applicable trade, all information requested below must be com leted by applicant. 'On File' is not an acceptable response.
... :.:..:�:.:• ::�::.::�,.::�:::.::..
Trade sif'rcation ;:>::: ; ::':::;:: ; <:::>> :.: :.:.:. :>
/ Ctas Contractor
.�:.:.: — .--.—Stam-.GontrActor's ... : .....:. .. ..:
-• ``�.WQrkers�.ConMpensat%n;iriSwai�C � a':. . ;;>::.. s::::... .' .:� . •Cit . sitle�s
EARTHWORK (C-121
CONCRETE (C-8)'
FRAMING 1C-5)
STRUCT: STEEL. (651)
MASONRY(C•29)
PLUMBING (C-36)
LATH; PLASTER (E-35)
DRYWALL (C-9)
Hvac to -2o)
ELECTRICAL. (C=10)' :.: - '
ROOFING`(¢39Y.'%'.>.'.'':.'.
SHEEt •METAL (G 43)
FLO RING IC:1'5).
GLAZING (C-17).`.
INSULA
TION(C-2)
SEWAGE DISP: (6--42)
PAINTING (C=33)
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING 1C-13)
LANDSCAPING (C-27)
POOL (C-53)
Company Name Classification License Number Exp. Date Carrier Name
(e.g. A. B, C-8) (xxxxx) (xx/xx/xx) (e.g. State Fund, CalComp)
i�66� . I I
Policy Number Exp. Date ILice ise Number Exp, Date
(Format Varies) (xx/xx/xx) (xxxx) (xx/xx/xx)
0031«' -v) I IN