9907-611 (PAT)k 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),,.`,
(),.,f "am exempt under Section B&P.C. for this reeaso '-' i
VDate .�- %�* �i Signature of Owner
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 'wotkers' compensation insurance carrier & policy no. are:
Cattier 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 Ahe 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'leo the workers'compensation provisions of Section 3700'of the Labor
Code I shall forth omply with those provisions..
�te: J'� " Applicant s✓ a>-"
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 orlproperty for inspection pu poses.
,..e. Jam~ R, el
ignature (Owner/Agent)--'�G ---- Date
BUILDING PERMIT PERMIT #9907-6,91
TRACT
DATE (►VALUATION yp LOT TRACT
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JOB SITE
APN
ADDRESS 74A10 SANITA DRIVE
6041.1CM*6
OWNER
CONTRACTOR /ttDESIGNER / ENGINEER
78910 SAN f:6 A 1)AL
1A Qii RNC.A. CA 92253
USE OF PERMIT
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RECEIPT
DATE ,
BY "'
DATE FINALED
INSPECTOR
or
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
Partv 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
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
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)
Final
COMMENTS:
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OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has beemsubmitted`in youiwname listing yourself as'tle builder of °the property
improvements specified `, • '" Y '
• _ 1
For your protection you shobld be,aware that as 'Owner/Builder' you are the `responsible party of record on such a
permit. Building permits are not re`quired:�to be signed by'proper y owners unless"ihey are p�e`�rsonally performing their
own work. If your. work '' being•performed by'someone other than yourself, you maypiotect yourself from possible
liability if that'person applies for'.the proper -permit in his or lies, namei'
` e ew � '• .'a. T` Z
Contractors -are requiredJby law,to be licensed 'and bonded by he,Sta of California'and to:have a business license
from the City or'County. They"are,also'tequired%y law ,to purthe-ir,license number,on all permits for which they
apply.5: ',. '' .t
s
If you plan to'do your own,work, with'ihe exception of various trades ihat'you:.lan to"ubcontract, you should be
aware of the`following information foryour benefit and, prote"cuon: ads t}
If you employ or otherwise: engage any persons other tl tan your immediate family, `and the work (including, materials
and other costs) is $200 00 or more for :the en iie, piojecc,a and such`y'persons are not licensed as contractors or
subcontractors, then-youmay bean employer. r :•.. . ' • , 4'` i;(
If you are an employer; you must register wit6'the:;State aril Federal Government as an,employer'and you are subject
to several obligations including State and Federal income tax withholding i''federal"social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation coriitibutions.
There may be financial risks for you if you, do not carryout these obhgations' and these riiks are especially serious with
respect to woiker's,compensation insurance. t"' ;' • �_ y
"" `. ' ;,- �i4=..ten L .. • YI
For more specific information about your obligations under Federal Law, contact the Internal Revenue Seivice (and, if
you wish; the. U:S. Small'�Busiiiess Adminsiiae�on). For more specYfic information"aboui your:obligations under State
Law, contact the Department ofBe"nefii Payments and"the Division of Industrial AcciBents. '
• 1. -.. a. , .� ��.. 4r s ,�r>Y /ee � 4� -� J
If the structure -is intended'for sale,, property owners,who are not license` contractors are,allowed to perform their
work personally or through their own employees, wit hour.a'licensed contractor or subcontractor, only under limited
conditions. • �. rte„
'. Yru: • ;( V .r - �- :yea• g IJ'•
A, frequent practice ofunlicensed persons,�professing to be contractors into secure anOwner/Builder" building
permit,'erroneously.implying,that, the,property:owner is, provtdingRhis or hcuown,labor and'matcrial,:personally.
Building permits are not requiredsig
sto�be ned: by property owners unless 'thy aree, performing their own work
personally.
Information about licensed'contractors maybe obtained'bycontant
ctrng the Coractors''.Siate License Board in,yout
03
community or at 10 N. _ Streei; Sacramento' California 95814 " �''' . ;' ►+' ;
Please -complete and"return the enclosed`ownet builderverrfica`tion form.so that.we can'confirm that you are aware of
these matters. The building.permit will not be issued until the verification is'tetutned. t
Very truly yours,
CITY OF LA.QUINTA
DEPT: OF BUILDING AND SAFETY,
78-495 Calle Tampico
La Quinta, CA 92253
(760)777-7012 r
FAX: (760) 777 70
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OWN IGNATURE/DATE''
,1 rY J 7 '
PROFtKfY ADDRESS.
PERMIT NUMBER(s) t M }
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