9810-125 (RPL)LICENSED CONTRACTOR DECLARATION
�I here(,w 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
!j
OWNER -BUILDER DECLARATION
�a
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. for this reason
Date 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
pe f
an of the work for which this permit is issued.
",+�`( )1:1: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: 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 asa 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/Agent) L�3�r?* Date
CONTROLN
BUILDING PERMIT PERMIT 9810.125
DATE VALUATION ��u,�os3.� LOT TRACT 8481
JOB SITE
ADDRESS :3-68.1. PALERMO CrAPN
`
OWNER
CONTRACTOR/DESIGNER/ENGINEER
BOBBY W. &'11 .A. L. 0.A.'nJN
(AN11—;1.1INT11'..DEr-11
43-&91:1.&LERM0 CT
LA (AUIal'.A. (:;A 92253
USE OF PERMIT
°OOL, ANDiOR SPA;
PO L AND SPA ON -LY
P::a'YL t\ADI 3R SPA, 10,000.00 LS
a.
P3a:lts'wi'ff )i:s SU.fiIMAII V
PLAN C;` *'.CKFE13 101 -1300 -a3 -9,;3i8 $76,0
Jr—T"704 f7pir 1,011.1—n-4) R-fk)SgJJ1�7
�.00)
M+CA`YICQL:jSC_".POOL Z01-000-421-WoW✓�.Vt�
UIXCrRICAL FE - I't(uOL 101.000-420-000
;N9.:1;W1'NO 1'f:G — POOL 1.01-f)(ilfA19-000 �x7.f►t►
4rii.'i
USS PRfPA1DF2MS
So, IN
'$ci':I:.'t L PERM IT FEWS 01JE NOW
��►�.#➢
RECEIPT {/ N.
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
Set Backs
Steel
Electric Bond
POOLS-SPAS
Footings
Main Drain
jD r��
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
Gas Test
Appliances
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:
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W - CA ---
BUYER/OWNEff/S ADDRESS CIT' RES. PHONE CONTRACT DATE
MAP BOOK PAGE
Owner and Contractor acknowledge that
they are responsible for the following:
Fence —
nceTei�ova! — Contractor/ —
-
F 2y___ __ ...- --
ent by
... ....... ...
Tree
1rtq Hauling liy.
P -q
Exeansion Retaining Walls y -y-
R
Deck Drains
Fencing by__.
Gates by
SALESMAN MUST INDICATE LOCA-
TION ON THIS SCALE DRAWING OF
ALL ITEMS LISTED BELOW AND THE
FOLLOWING MUST BE ACKNOW-
LEDGED BY OWNER. IF THERE ARE
ANY CHANGES FROM LOCATIONS ON
THIS DRAWING, THERE WILL 13E AD-
DITIONAL CHARGES.
Width Maxillitlill
Width - Minimum
length - Maxil!!YT
Length - MiniFIR1111
Depth - Maximum
Depth - Mininil.1111 :e LJ
Filter Location
Light Location P. Io
Ladder Location
Diving Board Location
Slide Location—
Heater
ocationHeater Location -___
--
Decking Location
Coping Location Z
Skimmer Location k 3:
Step Location 1., 0
Shape of Steps Coll
Access Dimensions 0
Tnjis &Toes of Slopes LU
C-0
Retaining Walls ow
Truck I-nad PoilJf
rov"Pre'd Patio 0
-1 -1 io
'" X
Gas-M'e',.i<
ei3-
Hose Bib °RITIs
Distance ii-c—o' —Pp --n I I r o i n
LU
House & Prop. Lirms >
OverheadUtilityLines. C)
Public Utility Easements—
Existing Structure or
J
Proposed Struct. on Prop.
ACCESS DAMAGE OR UNDER
GROUND OBSTRUCT!QNS:
—CG.'rhRAGF R will not assume
'responsibilityfr S damagi, Such as.
damage*'—
r"rbs, sidewalks, . driveways.
cement slabs.Sewers. lawns. frees. shrubs.
fences. telephone orother utility lines oN
rerouting of anv over head or UndF'.fqr0Und
lines. pipes. conduits or drainage. Customer -A
warrants all locations on this drawing are
within their propertylines. When access is
made through a neighbor's
ghbor's property. it is
understood that you.
. It' e ow mir. have that
neighbor's permission nod "Instinle 11111
responsibility. t,ito soil. rocks, debris. etc.
,Anioved or brought in ny.cept on Excavation
Day.
THE CONTRACT PRICE IS BASED
ON THE FOLLOWING MUTUAL
ASSUMPTION OF FACTS:
Thal the SOP has "IdQoU;Ite heating
capacity. contains no fill ground. no hard
Or rock formalionni boulders. contains no
resspo p IS. S e p I i C tanks. Underground
utility lines
ines or other obstructions. that no �
underground or surface water conditions
will interfere with the work of operation of
the corn p feled structure. that no blasting or
lack hammer work is required: that
trucks
and power and t, pril must have access to
QU; I
in
the site that said access is adequate and
substa n tial . and I warrant that there is
adeou ate electrical
le ctric a, and water sunnily avail-
able on the p,operly for construction PUr-
p.S' ,
S. , (?Iltrziclor shall not be liable for
flotation ol pool after guniling caused by
external water.
Grading in pool area only. limited to
30minutes. unlqss otherwise sp(icified.
Customer to be responsible. [at determina-
tion of pool elevation and drainage beyond
pool
d�,-ckinq. Walks and decking are not
gwirantepri againsl cracking. ch(!Cking.
raising. settling or discoloralion. Plaster
is nor guaranteed against discoloration.
Staining. checking or cricking. Such plaster
defects generally result from local wafer
conditions, improper use of chemicals, or
lack of or improper cleaning of the pool.
Any walls or grading not specifically on
contract. is owner's rr.,,00nsibilily.
Gontraclo,'s liability for v;,,i,,n ,! in
Poo I size st�all be,limiled to 53 00 a square
tool Should act ons of customer delay
consir, any additional r.o515 incurred
"y-iyf- -j!l he
"LIP lo mwh del, . shaft
boll". by C slon , q'.
rhis urian -,iiiihorrialion. Pri r:onitinction
with llieenlae
Cl. Ilioagreement 01 the parties.
BUYER APPROVES PLAN AND
SPECIFICATIONS AS OUTLINED
HEREIN, AND HAS RECEIVED A
COPY OF THIS PLAN.
SIGNATURE
SIGNATURE
Date
Scale 1/8', = P
Salesman
LEGAL DESCRIPTION - LOT TRACT
I PLAN Au-n-JORIZATION
JOB PHONE
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BUILDING &
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ACCEPTED FOR CON QW -FIRM 0110N
SUBJECT TO INS TIALLK-1111ON AS PER
AND ALL APPLICABLE CODES
-BY
LA QUINTA SUB. -CONTRACTOR LIST
_CITYiOF
Ua \ �qW M.6 C -t PERMIT NUMBER OWNER &666 Gck--LU BUILDER
JOB'ADDRESS
Building Inspection Card at all times in a consaiatious glace. Only persons appearing on this list or their employees are authorized to work
This form shall beposted on the job with the
on this job. Any changes to this list must be approved by the Building Division prior to commencement of Work. Failure to comply will result in a stoppage of work and/or the voidance
of 9permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is -not an acceptable response.
_.. _. Crt Business License
Trade /Classification Contractor < :;.;:::. State ;Contractoc:sLkense.. Workers;Com ,ersuranc... ...
Company Name
Classification
(e.g. A, B, C-8)
License.Number
(xxxxxx)
Exp. Date
(xx/xx/xu)
"' .Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK IC -12)
i12t�6?er
CONCRETE (C -P)
ri
FRAMING IC 5)
STRUCT. STEEL ;C-5 <
�QZO ?0b S
Q 4
J,�3 I-420
1ki199
_
-: ate► �
.
MASONRY (C-29)
PLUMBING (C.-36)
LATH, PLASTER (C-351
DRYWALL (C79)
HVAC (C-20) W!\�'l
ELECTRICAL IC 10)
Cj'�J\-CA v--\ 1
ROOFING (C-39):,,*...
l
SHEET. METAL`IC.-43``
`
:1 -;
FLOORING (C'=151
GLAZING (C 171:
INSULATION (C=2)
SEWAGE DI5P'IC=42):
PAINTING IC 33)
CERAMIC TILE (C 54) -.
CABINETS IC .0):: . ; ..'
FENCING
r
LANDSCAPING (C 27);
�.rfH�+."�i'�'��j�l��(�YO��li�� s���'�vas�`HS71kA�V" "5 �K at. =, _+7;,a,..:.9�`i'r/"'�+1R�.. rw'���Ti�Ft"��'iY'Y��? MZ►'�hri�^ �+-'��►.�'►'
OWNER/BUILDER. INFORMATION
Dear Property Owner:
An application for a 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 are the responsible party of record on such a .
permit. Building permits are not required to be signed by property owners 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 by law to be licensed and bonded by the State of California and m 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.,
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 the work (including materials
and other costs) is $200.00' or more for the entire project, and such persons are not 1¢ensed 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 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 for you if you do not carryout these obligations, and these risks are 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 Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of 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 to be contractors 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 per-orming their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' Sts.te License Board in your
community or at.1020N. Street, Sacramento, California 95814.
Please complete and return the enclosed'owner-builder verification form so that we can conf.rm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
' Very truly yours,
CITY OF LA QUINTA
DEPT.OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quirita, CA 92253
(760) 777-7012
FAX: (760) 777-7011
OWNER' S,SIIGNATURE /DATE «
--65� Pa•(��w.� c�r
PROPERTY ADDRESS
r,
w
PERMIT NUMBER(s),
t �,,