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0307-120 (BLCK)LICENSED CONTRACTOR DECLARATION. I hereby -affirm under penalty of perjury that I am licensed under provisions of Chapter 9.(aommencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. ,r License # Lic.. Class Exp. Date c 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). ( ) I am exempt under Section B&P.C. for this reason Date '1_ d Signature of Owner ~'3/%�' �•� - r "'rVr WORKER'S COMPENSATIONDECLARATION f/ 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 s tall 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. i 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 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/Agent) Date .��ppyyyy > I BUILDING PERMITi,QPERMITli ` 0307-120 S DATE VALUATION LOT TRACT 07fWiM s'i,500.00 ; JOB SITE APN ADDRESS 1 S C:A ,J ' pnmm769­06a-011. r OWNER CONTRACTOR / DESIGNER / ENGINEER MARK Hffd4AMJ,'_7 OWNMBUJIDER 50.625 GALL, PALCiN. A $.A QTMITA: CA 92253 sv) CA IA USE OF PERMIT (� �tYL�DI�I'fl 100 LF 6' ft= W Ai4.4 PXTER1OR SIDE YAI?MXI TY STANDARD 6 FT, WALL 109.00 LF E4`&WAs' 1 tOS" OF t:ONW—R-UMON P. RhM FM SUAMIJ1lRY C014STRUCTION FEE 101-000-418-000 $."M tJUL10 2003 CITY OF LA QUINTA FINANCE DEPT. SUB -TOTAL COMM rcryION ARD in" chmCK �ss�t.ucD USS PR&PAM) FSS suo RECEIPT DATE BY Cµ_ DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS SsM Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans OX to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wali Firewall Exterior lath Drywall - Int. Lath Final Frrr J BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs. Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. 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 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: 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:awarethat 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;unlessthey 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 tohave a business license from the City or'County. They a're' also required by law` to put their license number on all permits for which they apply. :r If you plan to do your own work; with the exception of vatic, 'us ;t-rades 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 sueh: 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 Governme_ nrasAn-employer and you are subject to several obligations including,Srate 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 carry out 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.the4fiternal'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, withouta licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to'be"contractors is i6secure an "Owner/ Builder" building,. r permit, erroneously implying that the property owner is poviding 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 contractors may be obtained by contacting 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�formso that we can confirm that you are aware of these matters. The building permit will'not,be issued, until the verification isreturned. - Very truly yours, CITY OF •LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760)777-7012 FAX:—C760) 777-7011 O E 'S SIGN /DATE ,S -0-16z_5 PROPERTY ADDRESS PERMIT NUMBER(s)