9609-163 (RPL)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).
X) 1, 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.Jor this reason
Date t" �� %" �% Signature of Owner >r --•f .,1�, . • * -'+. -`-.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: er .
( ) 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:
Carver 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 fl should become
subject to the workers' compensation provisions of,Section 3700 of the Labor
Gode, I shall forthwith comply with`those provlsions� `` /
VDate:AT' ' 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 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 represe °tatives of this City to enter upon
the above-mentioned property,for inspection purposes.
Signature (Owner/Agent)I ''y +�-- �• Date
PERMI
BUILDING PERMIT T# CONTROL#
!er�i�. �.cr:l
DATE 9123/96 VALUATION N15.00111.00 LOT. TRACT 4133
JOB SITE 'moi-a17g1't`i�.../0 �'1<�,
APN
ADDRESS
OWNER ?
CONTRACTOR/DESIGNER/ENGINEER
!i!•�fil :"(iii t{tCtAI�"+:a C •rAit,'13
YJ%A\t 14lAl,
p $IAIN/�.'I7 {�1 iYl Ylf: 1
1J PY 1,•—•\,6.iVIi+�.d:.ir�.
(A OU NTA CA
60 47
USE OF PERMIT
P00t, A,NL)fOR SPA.
iv:WX. A,, SPA, ONLYf.)iNNEM B61111)HR
R'S'..l'. MATED Car V.I* OV &;ONS`' IXTICYN
1.510 0.00
PERMIT FIN, SUMMARV
MAN C;f tP.CK Frtk 101-t)i)0-439-*
00NS' 'kiUC110N FIX 101-000-419-000 5162.00
-
Ntf CiiiV441CAL FiZ -. POOL 101-OM421.000 SM.00
�
Ff.E.L t'.RIf",A):. F><X -- POOL. 10140)420-000 $45.110
ca
Pf:flik 31140 TITs--F<.XXI 101-000-40.000
rn • _
LsJ
SUBJ.JI'.AL CONS'MUChOW:1',ND PLAN CH1.3 ",
S363.30
IaSS RRILF�:EIMD 1� �S
S0.00
' TOTAf,, PERMIT FEES 'DUE NOW
Y
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
Approval to Cover
Equipment Location
Underground Electric vu
Underground Plbg. Test
Final
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 102/
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures.
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
+I s.
OF 9wS 79-105 CALLE ESTADOV' — ^LAI.QUINTA, CALIFORNIA, 92253",
TELEPHONE (619) 564-2246 FAX (619) 564-5617
OWNER./ BUILDER. INFORMATION
Dear Property Owner:" r
An application fora building permit has been submitted in.yourname 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. Buildiing.permits are•not required to be signed by,Ji" rtyowners 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 bylaw 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. }
Jf'you plan to do your own work; with the exception of vari"uus 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 inclFederal income tax withholding; `federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks.foi you if you do not carry out these obligations, and these risks are especially serious with -
respect to worker's compensation'insurance. r
• 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 Stare
Law, contact the Department of Benefit Payments and the'Division of Industrial Accidents. f
Ifthe 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 coniractors ;is"to secure an "Owner/ Builder" building
permit, erroneously, implying that the property owner is providing,his or'her own labor 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 coniractors may be obtained by contacting the Contractors' State License Board in,your-.• ;
community or ai 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, y + }
CITY OF LA QUINTA 4
DEFT. OF BUILDING AND SAFETY
78-105 Calle Estado
La Quinta,, CA 92253 , 1
(619)564-2246
9) 564-561
OWNER'S'SIG ATUR E ,
70 AI -A
PROPERTY ADDRESS
-`ALA
A an
PERMIT NUMBER(s) . '
:.EF=1",�.-9 N1:1t4 11 :.=0 CIT`' C1 LA 1111IHTA E. 77 1011
CITY OF LA QU I N TA
SUB—LIST
., a
CONTRACTOR_ 9_ vs /W.eg ADDRESS_ -S7Ow � Cl/ie
OWNER_ Z& JOB ADDRESS_ C -At C4
This form'shall be {posted -on the job with the Building Inspection Card at all times In a conspicu6us plau.
'"it is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
are on this list are the same persons performing the work. Any changes to.this list must be approved the
City of La Quinta Department of Building & Safety 12x1.41 to work being performed by a changed sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit.
FF� --
TRADE
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SUB -CONTRACTOR'S
NAME'
TYPE OF
LICENSE
A/C -12
STATE
CONTRACTOR'S .
LICENSE
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61 3 �0 a_
WORKER'S
COMP..NAME/
NUMBER ON'FILE
CITY
BUSINESS
LICENSE
NUMBER/..
AXP, DATE;"
GRADE/
EXCAVATE
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C-10
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SHEET METAL
C-43
FLOORING
C-15
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GLAZING
C-17
INSULATION
C_2
SEWAGE DISP.
C-42
PAINTING/
DECORATING
C-33
TILE;
C-54
CABINETS/
INSTALLATION
C-6
FENCING
C-13
LANDSCAPING
C_27
POOLS
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