0205-282 (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).
( ) I am exempt under Section B&P.0 for this reason .
Date Abk 7- Signature of Owner
—j
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:.
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 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 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 or inspection purposes.
Signature (Owner/Agent)Date ✓ ,311L
B-.UILDING�PERMIT PERMIT#may
DATE..,„rt0�i VALUATIONN53 LOT TRACT
1
JOB SITEAPN
'ADDRESS. 50-4%0L,1A,,L 'y .oX PAJ O A.
,
OWNER
CONTRACTOR / DESIGNER / EN (NEER
50-680 CALLE PALOMA
LA Q01bTTA 9a23-
C1YUfi
USE OF PERMIT
1i'dA'3'ER HEATER CHA.iJ& OUT
VALVIATION L1.
PL.Y1MBING FKF 101-000-419-000 $22.50
Vis•%'`'LTR-:fl'�'C.P�dYLit i:IIJ €tT.3� t.C;%�.5f�
Yi���� 'ALP: WrrFE.s:aSDUE NOW
o�\
a
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
Retum 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
Underground Plbg. Test
Ficial
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:aware that:as."O.wner/Builder" you are the responsible party of record on,such.a
permit. Building permits are nor required to be signed by property owners unlesstthey are personally performing heir
own workAf 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 liy,the Stateof'California and to have a business license
from the City or County. They are 'also required, l y'law to' put iheir'license-,number on alf'permits for which they
apply.
If you plan to do your own woik, 'with' the exception,of;vanuus trades that you,plan,to.iubcontract, you should be
aware of the following information for your benefitand,protection:
Ifou em to or.otherwise.en a e an persons other than our nmediate'famil and the work includin materials
Y P Y g g Y.P, Y, Y� . � g.
and other costs) is $200.00. or more»for.,the entire _project; a"nd such persons are, not licensed as contractorsor
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;securuy taxes, worker's
compensation insurance, disability insurance costs and unemploym 'titcompensation contributions.',
There may be financial risks ,for you if you do not carry out these obligations, and these risks ae,especially serious with
respect to worker's compensation, insurance.
For more specific information about your obligations underfederal-Law, contact.the Internal Revenue Service (and, if'
you wish, the U:S. Small Business' Adminstration): For more specific information`about`youriobligati. s under State
Law, contact'the Department of Benefit Payments and the :Dtvision of IndustrialAccidents.
If the structure is intended for sale,,propeity:owners who'.are not licensed contractors are,allow.cd to perform _their
work personally or through their own _employees; without a' lice' ised coritiactor or subcontractor, only under limited
conditions.
4.
A frequent practice:of unlicensed persons professing to�be contractors is tosecure an,." Ow�fiir /Builderbuilding
permit, .erroneously implying that the property owner `is provtding dhis or her'own labor. andmaterial personally.
Building permits are not tequued:;to, be'`stgned ;:by property owners unless they are performing their own
personally s ,.Y
Information about licensed contractors may be obtained by coniacting,the Contractors' State. License Board in your
community or at 1020 N. Street, Sacramento, California 95814:
Please complete and'return the enclosed owner-buil&i.,verification form so=tharwe can confirm 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 . e` S.:L4,2
DEPT. OF;BUILDING AND SAFETY (O
78-495 Calle Tampico
La Quints,. CA 92253
(760) 777-70 2
FAX: (760 7-7011
O R'S SIdNAtUREi.DATE
50 -loco. AdL D'
�2 S
PROPERTY'ADDRESS `,� Q�) //U7�� � • J ,
PERMIT NUMBER(s)