0203-009 (SFD)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
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.0%for this reason
Date r U I', r ;. a Signature of Owner • r ti`
WORKER'S COMPENSATION DECLARATION--�c'"'
I hereby affirm, under penalty of perjury onp 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).
(4) 1 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, 1'shall forthwith comply with those provisions. S
Date: - : j - I j , Applicant �J
Warning: Failure to secure Workers' Compensatioon..coverage- 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/Agent) —� r.,:� " '�'••'` Date
PERMIT
- BUILDING PERM -c
• 203-009
DATE VALUATION $107,012A W LOT 104 TRACT Dr-I.WI. 1
f �
JOB SITEti-A5 �UAR01M.
ADDRESS S�'A
APN
617'13-(X.)4
OWNER
CONTRACTOR/DESIGNER/ENGINEER
U.10NI iM L.P. €
1DWRIMBUILDER
111 CM, A r CLU
1W.M DEWWT V2260
USE OF PERMIT
MOLE FAWAr DWF_LL A 0
;�r r •V4KAOFf LX)V-S NU•1' arrc;LU Z Uz;caU . WJU.4, P00L. QK 1JY.tVZ h
APPROACI1. 'N CODE.
TRACT CONSTRUCTION 2,212.E a1p
.PORC".AT10 16.00 5F
tirA.11_AMUCAR.PORT 47.90 U
Eg"MU .D COST OF CCAMUC17,+ 1ST
10 7,012.80
PEMT1'!n`1::IL" qp UMMARY
CONSTRUCTION FEZ 101 -MV -418-000
PL.F1N fbfi{FXK WE. 101<000-439-318
FEE DEPOff6 f 101-000-439-318 4250100
iiREi.'I-1.c LAICAL FRE 101-fttya-4.21.-1700 $68.50
ELECTRICAL 101-000.420.000 S120.S4
PLUM B N O FEE 101-000-4-19-000 $122.7.5
STRONO MOTION FEE ..RUID 101-000-241-000 310.73
Ci1dADI NO PEE 101-000-423-000 $.M.00
DWELOPEI1.IMP. CT rEE 31,9;Y3.@0
o�
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I:ll.dL—TOT'•t9._• C ONTOF.1R' 4./i.TIO f11 -6D A;1•>!.`7 (JWK
5
LRSS PRB-FAM FEE:)
4250.00
9,i5'JA
IRT.11,
C61yor-LAQ
'RECEIPT
DATE , I
BY
DATE FINALED
INSPECTO
OZ—
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
, ptiCIS.
Ducts
Slab Grade
Return Air
12" 2V
Steel
Combustion Air
Roof Deck
_ O -d
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Q
Compressor
Insulation
• J Z
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
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
p
770
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
A_
02— ��
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) /
ELECTRICAL APPROVALS
Temp. Power Pole _/Q a ?/
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)
�� �r '" •:}�\ ver,yy: -- r, ,t. sr. ..�- A. . q. - r-.•,•T.�-m.;yA'"�ir')w'9+"15'yy".•'z`+� 1�'te�ryr�.gro ,T 'v.p•yer�,a �• fr�"�.�r�^w*-r a,Tr:Y4
I-010 If,<r,. x
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BOX 1504 APPLICATION ONLY
Building . (` � Cr (c'� �' �}'�� LA QUNTA78-495 C
Address CAL CALIFORNIA 92253
� .>
OwnerrCfVnt\ L Aft1 6/7 393 -may
Mailing
BUILDING: TYPE'CONST. OCC. GRP.
Address fir,! ( A.P. Number—
City
��'"
City JttZip / Tel.
Legal Description / 7
ntractor
Address
kk.L,x-r11 ! a ,-I c.
city r Zip Tel. F'
State Lic. City
& Classif. Lic. It
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (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. 7031.5,8usiness and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to 'Its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
[ 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, Bin sness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
Provided that such improvements are not intended or offered for sale. If, 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 build or improve for the purpose of sale.)
1] 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct 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 will,a contractors) licensed pursuant to the Contractor's License Law.)
1*7 1 am exempt under Sec. B. 8 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 Compensatiorrinsurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. ' Company
1`7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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., If, 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
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's' Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I 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
Project Description <
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setbalk from Property Line
FINAL DA'
Issued by:
Validated
Validation
WHITE = FINANCE YELLOW = APPLICANT
PINK = BUILDING DIVISION
Sq. Ft.r i
Size =-
No. No. Dw. !
Stories ( Units
New; 7 Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
2 U
Plan Chk. Bal.
Const.
Mech.
Electrical
-'
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setbalk from Property Line
FINAL DA'
Issued by:
Validated
Validation
WHITE = FINANCE YELLOW = APPLICANT
PINK = BUILDING DIVISION
Recording. Requested By
First American Title Compay
RECORDING REQUESTED BY I
AND WHEN RECORDED MAIL TO:
Leonard Lam
111 Chelsea Circle
Palm Desert, CA 92260
A.P.N.:646-313-004 TRA,/l:
pao-Oya-
Doc . s: - ;2001-082170
02/28/20W.88:00A Fee:8.00
Page"1 of I'Doc T Tax Paid
Reeordad .in �Off;.icial Records
County of Riverside
Gary L. Orso
Assessor. County Clerk 8 Recorder
I'
GRANT DEED
THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER TAX IS: COUNTY $26.40
JXJ computed on full value of property conveyed, or-
] computed on full value less value of liens or encumbrances remaining at time of sale,
] unincorporated area; [ City of La uinta , and
FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged,
M. M. Miller, a widow
0
hereby GRANTS)to Leonard Kinchiu Lam, a Single . Man
O
Q the following described property in the City of.La Quinta, County of Riverside State of California;
Lot 104, Desert Club Manor Tract 1, MB22/53, County ofRiverside,* State of California
I
nnn
Document Date: January 17, 2001
STATE OF CALIFORNIA )SS
COUNTY OF i9m
On O 0/ before .:me;
personally appeared m AT- sejjq!;y-4PQwn to
(or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signature(s) on the instrument
the person(s) or the entity upon If of which the person(s) acted, executed the instrument.
WITNESS my ha official seal. .'• °�•].N Dianna Redman
U :c '�(� Comm. #1160633
(j q. arta rt,NOTARY PUBLIC. CALIFORNIAN
v; ^ ORANGE COUNTY
Signature .'' Comm. Exp. Dec. 3. 2001
This area for official notarial seal.
Mail Tax Statements to: 'SAME AS ABOVE or Address Noted Below
MEEMMMMMMM
IMMMIMMMMMMM
GRANT DEED
THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER TAX IS: COUNTY $26.40
JXJ computed on full value of property conveyed, or-
] computed on full value less value of liens or encumbrances remaining at time of sale,
] unincorporated area; [ City of La uinta , and
FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged,
M. M. Miller, a widow
0
hereby GRANTS)to Leonard Kinchiu Lam, a Single . Man
O
Q the following described property in the City of.La Quinta, County of Riverside State of California;
Lot 104, Desert Club Manor Tract 1, MB22/53, County ofRiverside,* State of California
I
nnn
Document Date: January 17, 2001
STATE OF CALIFORNIA )SS
COUNTY OF i9m
On O 0/ before .:me;
personally appeared m AT- sejjq!;y-4PQwn to
(or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signature(s) on the instrument
the person(s) or the entity upon If of which the person(s) acted, executed the instrument.
WITNESS my ha official seal. .'• °�•].N Dianna Redman
U :c '�(� Comm. #1160633
(j q. arta rt,NOTARY PUBLIC. CALIFORNIAN
v; ^ ORANGE COUNTY
Signature .'' Comm. Exp. Dec. 3. 2001
This area for official notarial seal.
Mail Tax Statements to: 'SAME AS ABOVE or Address Noted Below
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 record on 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.
r,
If you plan to do your own work with the exception of variuds 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 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 State
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.
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 Jabor 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
78-495 Calle Tampico
La Quint$, CA 9225
(760)777-7012
FAX: ( 77-701 A
O ER'S SIG ATE
p �- Cir�z
"C 92—
-
D?��"
PROPERTY ADDRESS
bZo3- Oct
PERMIT NUMBER(s)
CITY OF LA QUINTA SUB -CONTRACT UK LI, I
JOB ADDRESS PERMIT NUMBER OWNER 4F—o�vgnA 64/1-% BUILDER
This form shall be posted on the job with the Building Inspection Card at all simes in a conspicuous Rloce. Only persons appearing on this list or their employees are authorized to work
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 voidance
of building permit. For each applicable trade, all information requested below must be completed by aoolicant_ "On File" is not an 2rrantnhlc raonnnca
•^ x
s
Trade L. C1�ssihCaUon�tgte.Cprltractor,s�i+e4psu
w
Company Name
Classification
License Number
Exp. Date
.'grrier Name
Policy Number
Exp. Date
License Number
Exp. Date
(e.g. A, B, C-8)
(xxxxxxl
(xx/xx/xx)
(e.g. State Fund, CalComp)
(Format Veriest
(xx/xx/xx)
(xxxx)
(xx/xx/xx)
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75�945
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up 1640402
10/01/02
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Ala
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Ld Quinta Air-conditioning
C20
749342
5/31/P2
Exempt
n/a
n/a
05951
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Orte a and Son's Roo
C-3
762849
3)-31/03
State
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C-17
737824
7/31/01
State Funds
1396204
6/1/0
3085
12/31/
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ParngINst�4�lory Insulifinn_
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