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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.
L".cense # Lic. Class Exp. Date
D§,`R• ' Signature of Contractor
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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.C. far this reason
Date I•i Signature of Owner—__ .--.
WORKER'S COMPENSATION DECLAAATION
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 p-,rmit 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' compensatlon provislons of Slaction 3700 of the Labor
Code, i shall forthwith comply with those ovisions.[
Date: Appllcanf_ --- `'-
Warning: Fallure to secure Workers' Corjpertsation coverage is unlawful and
shall subject an employer to criminal penalties and civll fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information Is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned property for inspection purposes.
Signature (Owner/Ageritl�-� _ .
BUILDING PERMIT PERMIT# .
DATE VALUATION LOT 0104- 12$ TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
h i i 3► JAi� ?I,3 Ci C i,FL.VIT
1 A WiR 71. 1.A 92253
e,
USE OF PERMIT
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APR 13 2401
CITY OF LA QUINTA
FINANCE QEPT
RECEI UAI tz
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs I Underground Ducts
Forms & Footings Ducts
Slab Grade I Return Air
Steel
Roof Deck
O.K. to Wrap I
Framing —
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath _
Drywall - int. Lath
Final rl
ELOCKWALL APPROVALS
Set Backs
Footings J
Bond Beam J
Final I I _
PLUMBING APPROVALS
Waste Lines I I
Water Piping j
Plumbing Top Out I J`
_Shower Pans I
Sewer Lateral
Sewer Connection
Gas Piping I
Gas Test
Appliances
Final I _
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures J
Main Service
Sub Panels 1
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Combustion Air _
Exhaust Fans
F.A U. _
Compressor I _ t
Vents f
Grills 1
Fans & Controls
Condensate Lines
Final j
POOLS -SPAS
Steel
I
I`
_
I
Electric Bond
Main Drain _ !�
Approval to Cover — �I
Equipment Location
I
Underground Electric
Underground Plbg. Test
�_
( !f
Gas Piping
Gas Test
Electric Final
Heater Final j
Plumbing Final _
Equipment Enclosure
O.K. for Finish Plaster 1
Pool Cover
Final
COMMENTS.
Bin #
City of La Quinta
Building 8r Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (619) 777-7012
Building Permit Application and Tracking Sheet
Permit #
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Project Address: X t }-�j �� -% �,Lr o L�
Qwncr's tvame: ��r� 1,use�c
A. P. Number:
Address: iL SL"'1r,.0
Legal Description:
Contractor: vt
City, ST, Zip: 21 C K ct 2Z5 -5
Telephone: ?(
Address:
Project Description: V aQ-A C
City, ST, Zip:
C ��
Telephone:
State Lic. # : City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person:
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person:
Estimated Value of Project:. -2 o p
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Grant Deed
Plans resubmitted
Mechanical
School Fees
2"" Review, ready for corrections/issue
Electrical
�
Subcontactor List
Called Contact Person
Plumbing
Planning Approval
Plans picked up
S.M.I.
Pub. Wks. Appr
Plans resubmitted
Grading
H.O.A. Approval
'" Review, ready for corrections/issue
Developer Impact Fee
Called Contact Person
A.I.P.P.
Date of permit issue
IV
Total Permit Fees
No?� ,• j�,.uv,G� w�o�0 �acl s��'� �!�.w�P 7� �r�.l��
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OWNER/ BUILDER ••INF.ORMATION
Dear Property Owner:
An application fora 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 not rear theresponsibl party of record on such a
permit: re quired„to be ignd by property owners unless they;aresprsonally performing their
Building permits a
own work. If your work is; being'performe, n
by someoe:other,than .yourself, you:may protect: yourself 'from possible
liability if that person:applies'for the.proper permit,tn,Nis or lief name. ,
Contractors are required by law to bic.sdand onedd f Cilifointa and `to have a business license
from the City or: County. They'ire 'also require&by law: to put iheirt license. nui b6&: on'all permits for which they
apply. r
If you plan to do'your own work �with'the exception ofwariuus trades that you;plan`to subcontract, you should be
aware of"the following informationfor your benefit and,protecnon
If you employ. or otherwise(engage.any persons other than youi immediate family, and the work'(including materials
and other costs) is j200.00 or more, for`th'e` enure:project,:and such•";persons•are not Aicensed as contractors or
subcontractors;•then'you may be an employer..~
If you are an. employer, you must regtste'r r'egiste'r -w... the Statehand Federal Government as an employer, and you are subject
to several obligatio, ns including' State and,Federal'tncome tax withholdi6g, federal''social security taxes; . worker's
compensation,insurance'; disability,tnsurance4costs and. unemploymentcompensation contributions.
:. .' - : ,5`ro>4 r w7a •w..,moi S�5 + _ E �`
There may be financial risks for.you if you.do not c..arry ouf these obligafi°ons'and these risks are especially serious with
respect to worker's c'om'pensation insurance.
For more sp'eci'fic information about your. obligations underFederal Laww;contact+the Ine&nialRevenue Service (and, if
you wish, the t1S Sriiall,Busmess Adminstrauon) For more specific triformaiion abouc�your'obligation ,under State
Law, contact the Department of:Benefit?Paymens and -t6 of Indusstiial'Accidents:
If the structure is intended for sale property owners w,ho are not licensed contractots 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 profeistng to be con tactors is to secure an- ' "Owner/ Builder" building
permit, erroneously impYlying that'•,fhe property°owner is providing hist' or he% own,aabo�r and`Ymaterial personally.
Building permits are- not;required to be signed` by?property owners:;unle`ss',they are, performing their own work
personally.
Information about licensed contractors. my..be obtained :bycontacting 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 co■nfirm that you are aware of
these matters: The building�permi will'not be issued until the verification is te�turned. ^-
-. :.e:.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico t
, La Quints; CA 92253: `
(760) 777-70'12. r
FAX (7 777
OWNE IGNATURE%DATE ,
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PROPERTY•ADDRESS
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PERMIT NUMBER(s)
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