9610-022 (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 in full force and effect.
License # Lic. Class Exp. Date
'f
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
W
nse 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). 4
O I am exempt under Section B&PO for this reason/),
`bate/Q&/_9'6 Signature of Ow,n/e,-�
�rf_o
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, forthe
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.5TA "E Fv� Policy No. 1 A 1.36/ 5 —"11'40
(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 s all forthwith comply with thh to provisions. A
afr% Applicant 4 ` --
Warning:,'Failure to secure Workers', Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth -on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection
`,pju�rposes f
/Signature (Owner/Agent)/ -� ,.+r,. tis• yle44 �. Date a/T6
BUILDING PERMIT
DATE 101419-6 VALUATION :i'.s3:juioux) LOT
JOB SITE
ADDRESS 51-295 CALLE QkII O
OWNER
G.F01i IMIA C LAA.KE
P.O. k3 X 1490
LA 01.11ir TA CA 92253
USE OF PERMIT r
P(.)0k,AlvlVOR.; PA
PERMIT# CONTROL#
%110_02241.$ 7,
TRACT
APN
CONTRACTOR/DESIGNER/ENGINEER
OWNER r MJiIAX.R
T 701"
PC144111' FEIP;St<IN•I14IAR
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101. (kj 4, 9' M
$64t 35 .
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. lA.!-�JO(?-4184)00.
$99.00
fief MiANK.*AL Rli -- POOL
101,W)-421-000
$24.00
0<t?C" R K",!'+(. WE -- PCX)I,
6)1-0()0-Q0.t)(110
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SLIB-'tom' A L C.'ONSTRUMON AND PL,401 Ct1.EC.K.
P.:i'sSS ,VXE -PAI 0 FF,CS
RECEIPT I DATE I BY V A 1 DATE FINALED I INSPECTOR
C.'TILH
8103 i.00
50,00
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel 14 4e 1q,
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas P'
PLUMBING APPROVALS
as Test
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:
BuildingC/�
e Address a `'
P.O. BOX 1504 APPLICATION ONLY
78.105 CALLE ESTADO
LA OUINTA, CALIFORNIA 92253
� r
Mailing
•'
Address �Ci 14
0/(
CityZip
J�el.6L 6)u 02E3
Contractor .
i7lA p /1 `
Address
•
•
State Lic.
• & Classif.
City •
Lic. N
Arch., Engr.,
Designer �6CLO D L ,-
Address _ A Tel.. /
City IZIP State
Lic. #Col �_3
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Business and Professions Code: Any dry' or county which requires a
permit to construct, after, inprove, demolish, or repair any structure, prior to as Issuance Also
requires the applicant for such permit to rile a signed statement that he Is icensed pursuant to
the provisions of the Contractor's License Law, Chapter g (commencing with Section 7000) of
Division 3 of the Business and Professions Code. or that. he Is exempt therefrom, and the basisfor the alleged exemption. Any violation -of Section 7031.5 by any applicant for a permit
subjects the applicant to a civit penalty of not more than five hundred dollars'(S500).
i as owner of the property, or my employees with wages as their sole Compensation, will
t6j
do he work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
Wills or improves thereon and who does such work hkmelf or through his own employees,
provided that such improvements are not intended or offered for sale. a, however, the building
or improvement' is sold within one year of completion, the owner -builder will have the burden
of proving that he did not Wild or improve for the purpose of safe.)
t �-a, as owner of the property, am exclusively contracting with licensed contractors to con•
. strict the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
i 1 am exempt under Sec Tlq B. g P.C. for this reason'
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Comp nsatins
on Iurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
Policy No. Company
f] Copy 5 tiled It city. Q Certifi opy is hereby turn Ishd.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed If the permit is for one hundred dollars (5100) valuation
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.
Date Owner
NOTICE TO APPLICANT: N, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3087, Civil Code.)
Lender's Name
Lenders Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 100 days.
I-certilythai 1 have read this application and state that the above Information is correct.
1 agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives .of this city to enter the above•
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City,' State, Zip
FINANCE
BUILDING: TYPE CONST..
A.P. Number �"4
Legal Description¢
Project Description*
l' OCC. GRP.
"� 14 � L
-
Ste ! 114 %
Sq. Ft.
Size
NO.
Stories
No. Dw.
Units
New' Add O
Alter b
Repair O Demolition O
Estimated.Valuatione
Ocio
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech. '
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setbadk from Center Line
Rear Setback from Rear Prop. Line.
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: DE.te Permit
Validated by:
Validation:
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 recordon 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 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 variuus 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 wo-k (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 bean 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 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,
tareLaw, 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.
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 property 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 N.'Street, Sacramento, California 95814.
Please complete 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.
Very truly yours
CITY OF LA QUINTA'
DEPT. OF BUILDING AND SAFETY .
78-105 Calle.Estado
La Quinta,, CA 92253
(619)564-2246
4:F(619)564-5617
SIGNATURE/DATE
PROPERTY ADDRESS
PERMIT NUMBER(s)