0103-121 (PLBG)LICENSED CONTRACTOR DECLARATION.'
I hereby affirm under penalty of perjury that.l 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:
( ) d, 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).
1 am exempt under Section , B&P.C. for this reason
Date '� 1 /" Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pe;Ialty 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:
Cartier 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,
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 shall forthwith comply with those.provisions.
Date: Of Applicant
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 acid 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 aut X few rep�ese tad sof Rhi gity to enter upon
the above-mentioned property fo hspectj p(l�posea�f ��d 13t�� J�1 `•
»--Signature (Owner/Agent)!-,''r � Date �-'" t.
BUILDING PERMIT PERMITN�
DATE VALUATION LOT �a. ;Yl J�� TRACT'
asm '.60
JOB SITE
APN
ADDRESS
78-= SAGUARO ROAD,,
_ ..
OWNER {
CONTRACTOR / DESIGNER / ENGINEER
PAT DALMMR.l D ]'c T{Cg1001Y
C)WNFA 9011)FA $
?8-7:10 SACYiT.Pr.RO -ROAD
1A Q) JMA CA 92253
USE OF PERMIT
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MAR 15 2001 i 12.13 PRE-FAID FERE
$0,00 ,
LA?,-��AAL YCESDICIF. NOW
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RECEIPT
DATE:'
BY
DATE FI ALED
�/_ �/
INSPECTO
t
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
S _S
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
(o — l — +� S
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
r
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:
m
r
OWNER / BUILDER INFORMATION
Dear Property Owner:
y + *rt:. '
An a pplication,for a bwrldipg permii has been subi, d -in youi;name listing yourself as the builder of the property
improvements specified. ; , , �►'. ,
For our protection oushould be�aware that as 'OwnerlB`uilder you are the its onsible art of record on such a
Y P Y 4; Y P party-
permit. Building permits; a e`tiot�tequite�d46 be signed byprgpe y owneisyunless they are personally performing their
own work.:If yourcwork•is being pe'forme8,Eby someone other thanyourself yo'u may protect`yourself from possible
liability if that "person applies forah "proper permtt"ii i''s of her,name. �:.t
Contractors are.required.by law to be,licensed and bonded, by the State of CaliforntaranS o have a business license
from the City°or County. They. a e°.also °required by is to put their, icehsenumb on tall :peimits for which they
apply. F
If -you plan to 'do your own'. work .wrth-the exceptionof.variuust.rades that youplan.to subcontract, you should be
aware of the`following " formation foc.your benefit and protection
If you employ or otherwise.engage'any,personsPother than your immediate #amily and4the work (including materials
and othei,, costs) is $200.0V6 ' more for the en'tir'e tproleci-, ,and 'such persons are not flicenied 'as contractors or
subcontractors, then you may -be an employer.
If you are an ertiployer ,�.you,must register.wrth the'State and Fedeial Go"vernment as,an:employer and'you are subject
to several'obligations.includingBSt'ite and,.Federal Jricome tax-`wtthliolding' `fedetaLsocial, security, taxes, worker's
compensation insurance, disability insurance costs andlun'ertiploymenrcompensauon contnbutions.
There may be financialrisks.for you if y6u' Ao not'carry our these obligations and these�risksjare especially serious with
respect worker's
For
insurance. i '
wA7.
For more specific information about your obligations,under Federal Law, contact the Intimal Revenue. Service (and, if
you wish ""the U.S. Sma11;- Bu, sine.ss Adminsirauon) Forrmore speufic'tnfo Xmauon about your obligations under State
Law, contact the Department of Benef t Payments arid• tl e' Division of Industrral:'Accideints .
If the siruciure is intended for sale property owners who are not.luensed'con ractots,are ,allowed to perform their
work personally.'or through their own•employees,';without a hce_n"sed contractor orsubcontraetor, only under limited
conditions. j t
A frequent ,practice of,unlicensed,persons professing to, be contractors -,is ito secure an ' OWner/Buil'der" building
permit, erroneously implying that .the property oainerrs provrdmg hispor her own -1abor and material ,personally.
Building permits are not tequire'd .to be srgnedsby-property-owners unless: they are,performing their own work
personally.
Information about licensed contractors may be o`btarned,byaconticti g --,the C'o`ntractors' State License Board in your
community or at 1020 N. Street,;Sacr'amento, Cal fornix 95814.' `s
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.beiissue'd until i.lie verification .s�returtied.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF_BUILDING AND SAFETY
78-495 Calle Tampico
La Quin 92253
(7160) 1 7-7 2
7 7
`'F
O*NER S SIGNATURE,/DATE t.
-70
PROPERTY ADDRESS' .
03
PERMIT NUMBER(s)