0308-291 (RPL)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 iri 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). / / f
( ) I am exempt under Section , B&P.C. for this reason
Date ,:,�';/,;;., f,;x 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 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,
Qhall 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/
,eDate: y- o"? i! � :� Applicant—
Warning:
pplicant
e. .. .. i..^ ....,...
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 attom4y'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) Date 42 ✓ ��"•�
NI
PERMIT #
PAW
PDAMILDING 0131IM-i9l,
DAT,E,/ VALUATIONLOT TRACT
JOB ADDRESS -7'7QD R CH.. SAH' •T��a��..P?
i
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
'tid;;kRQ,,A= L .J0kTES
b3I3I;3ff)ER
7-.A!CR`jJ1,c A, *C4A 92-253
USE OF PERMIT
4. F.44 4 t" r V.4. .i d.q.+5ly.. Ap Eye . I t'-c�1 i�P ri:,xy...
V' �Vpi,(H� ,s
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003
4 FT. W,W4; Do 41V
LA (dUiA1TA
POOL JGNIV k EPA x+,%+6.00 Ls CITY
OF
ANCE DEPT.
FIN
' 'SIT r' QED tv1_X� (W t:"RYA'MION
R4 .�1?D41.+t�Gs
FLAB A CHECK FET 101 -00, 439.318 S76M
C'.ONSTRIUCTIO14 'FE& 101 -OW -418-000
MWt AWIC'AL FEE -- POOL 101 (00y 421400
,�gg
ELLP rIf�� (CALL fl E — pl)OL 0i "�7;.J':0-+ 20.1000
PLUM19.140 RE.— POOL 7 01 -000-4 19-000
' a.,sr017 PRE PAW rm. 9
tliW."�V
':�«`Y'f9:}.. � ��f �.� Iiy1:�' 1`70��
sir�.%.Q7��•r
RECEIPT
DATE
BY �. j
DATE FI ALED
INSPECTO '
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover -
Equipment Location
Underground Electric j - 3
Underground Plbg. Test
Finn
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
,Waste Lines
Heater Final
Mater 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 Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
5
c�M OF i 9� E 78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253
L ' �
.TELEPHONE (760) 777-7012 'FAX (760) 777-7011
OWNER /BUILDER INFORMATION _
Dear Property Owner: ti
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
r 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 severalobligations 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 Stare
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.! `
r_ A frequent. practice of unlicensed persons professing to-be contractors is to secure an "Owner/Builder".building ,
y' permit,'�erroneously implying that the property owner is,prov►ding his 'or'h(er own labor and rnaietial'per'sonally.
'Building permits are. not required to be signed by property owners unless they are performing 'their own work`
personally,
r
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 comp'leie 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. t
Very truly yours;
CITY OF IA QUINTA
DEPT. OF BUILDING AND SAFETY ,
78-495 Calle Tampico
La Quinta, C�9�
53
(760) 777-
;t
FAX (760 -7 1
O R'S GNATURE/DATE
Aaadw-.
OPERTY ADDRESS
0 308= aq l '
PERMIT NUMBER(s) 1
r
KU
LOT 13 TALANTA CITY OF LA QUINTA SUB-CONTR, /ACTOR LIST
JOB ADDRESS 49-770 Rancho San JulianPERMI- NUMBER OWNER � i a-rw ScA-- L S o rt�e-S BUILDEF
This form shall be posted on the iob with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or the
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 st
of building permit. For each applicable trade, all information requested below must be comp€eted by applicant. "On File" is not an acceptable respoi
Trade'/ Classification
Contractor
'State.:Contractoc sLicense .
WorkersCompensation Insurance
Company Name
Classification
(e.g. A, B, C-8)
License. Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
(C".
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