0101-272 (PLBG)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).
O I am exempt under Section, B&P.C. fort. N,reason
Date ` ��.`� ' �' r ' Signature of Owner r
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,
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: t • ? " ' 7 Applicant—
Warning:
pplicant 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 ar oses,
Signature (Owner/Agent).!'' .tip,...- � �.. Date"2
BUILDING PERMIT PERM T#
DATE VALUATION LOT TRACT
+ 112AW: �.�PfD�Q387
JOB SITE
APN
ADDRESS
4-815 CA1,1J.' &ANTA PARBER46
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.1R3:0IAE? 1>a:
i�I Ian
�T
USE OF PERMIT
60 Lif V OAS f..f'1VE?. TO STtfB•CDUT 110, Ft.f'f`LIRM SPA R}SQ FIREY.PM
VALUATION IKOD is
:s
111UMMED COW OF CONSWR :TC- ION
3QYra.Csti
KE 6.1,1014WARY
PLUMBING 1712
RM -TOTAL COXIYI�UC'x':f.ON AND V LA R eaIYCX
$18.00
LESS FRE -PAI IPMJ
$0,00'
ion
JAN 2 5 2Q1,
N 19 Y g
RECEIPT
DATE11rr (g
BY.;
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts [
Slab Grade
ReturnAir [
Steel
Combustion Air [
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U. j
Framing
Compressor j
Insulation
Vents t
Fireplace P.L.
Grills j
Fireplace T.O.
Fans & Controls [
Party Wall Insulation -
Condensate Lines
Party Wall Firewall
[
Exterior Lath
[
Drywall - Int. Lath
j
i
Final {
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel {
Set Backs
Electric Bond [
Footings
Main Drain
Bond Beam
Approval to Cover f
Equipment Location [
Underground Electric [
Underground Plbg. Test [
Final
Gas Piping {
PLUMBING APPROVALS
Gas Test I
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 j
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
Syh Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
OWNER /;BUILDER. "'INFO R'MAT'ION
Dear Property Owner -
An application for a building permit has been submitted in.your.,name listing yourself asthe builder of the property
improvements specified.
q - L
For your protection you should b&aware`that as "Owner/Builder"' you'are the responsible party of record on such a .
permit. Building permits are not iequired.to besigned by property owners unless' They are personally performing their
own work: If your,work is being'pe.�formed by, someone other. than yourself,,you may- protect. yourself from possible
liability if that person applies forthe proper permit -in hi"s' or' her. ame.
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 `piir their" license'numbe 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 thework (including materials
and other costs) is $200,00 or;more- for the, enure 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:,Siaie•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 foryou,if you do not.carry out, these obligations, and_these>risks'ace 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"BusinessAdminstration).--For more sp6ific=informa6on,abo6t your obligations under State
Law, contact the Departmeri cif 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,tube contractors is to secure an "Owner/ Builder" building
permit, erroneously implying thaf the property owner is providing. his,or;her•own labor.and material personally.
Building permits are not required to be signed .by p`roper'ty owners unless they are .performing' their own work
personally.
Information about licensed' 'coptractots may. be obtained: by contacting the'Contractors''.State License Board in your
community or at 1020 N. Street,'Sacramento, California 9,5814.
Please complete and return.the.enclosed owner -builder. verification form so that'we can confirm that you are aware of
these matters. Thebuilding permit'will not beissued' until the;verification is;returned .
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7 2. .
FAX: (7G 77- 1:.
as�2
OWNER'S SIGNATURE/ DATE
Xq elgI5 cotr C
PROPERTY ADDRESS
PERMIT NUMBER(s)