0011-236 (AR)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
dompensation, 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).
O I -am exempt under Section B&P.C.�for this real ���n I i
,Pate Ar 66 Signature of Owner .+ti1�.�.a..n�.a
r V
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:
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
worker jcompensation laws of California, and agree that if I should become
subject to the workers' compens tion provisions of Section 37 0 of the Labor
Code, I sh II fo hwith comply with�, �those pro I Ions.
,Xte: 1 r7 t !7 Applicant WILD ,.V .
/ _ . V
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 r
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 r inspection purp6ses.';
,Signature (Owner/Agent) Date®
_BUILDING PERMIT PERMIT#
DATE LOT 00-11•'1.'W TRACT . .
7VALUATION
/2
JOB SITE
APN
ADDRESS 50-920 C.Au1<..ct:. OBISPO
789-072-•007
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C� 1�,T) )• 0AUDER
OWNT'�t,�'1,71Lr) 1t
L&QUDrr.A CA 92253
USE OF PERMIT
Ct3'NV91ZT EXISTING QkR.A.139 INTO 4,17 S.*F. BONUS ROOM; 509 S.Fr
QAlt.A09 ,Af.)DITION
B014UP Room 482.0010
OARA09 509,011 SF
ERMUT03 COST OF LONSM'l17M1 1ON
26,701W
PLAN CHECK 1?� 101-000-139-318 �21°i,f►1
CONSTRUCTION TION 101-(3(111•418-000 �d6g.Q0
M9,C1dANICAL ".9 101-000-4.2t-,000 $40.50
1Y% TRJC,ALMY, 101-000-420-000 $44.03
PLUMBING FEE ' : 101-OOV-419-000 � 46;Otl
STRO'NO MOVON FIE - zlMID 10.1-000"241-000 �i.•5?'
CiItPXWO FU 101 -000.4234)00..
t
w�
SUB -TOTAL COMSTRUCTION ANDPLM C M=
$617.83
IMB PRE -PAID FFWS
$0.00
w
� ROW
? TOTAL IUMIT YM0 DUE
"17W
NOV 2 9 2000
a/IT Y `ii- LA U��N
(RECEIPT
DATEBY
/;,�
DATE FINALED
INSPECTOR
1112. ,
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 _A&/_4
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
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:
Desert Sands United School District.
47 950,Dune Palms:;Road
Notice: La -Q i, 92253 .
Document Cannot Be Duplicated 7.60r77.L8515.
CERTIFICATE OF CONOLIANCE
Date 11/29/00 APNV 769-072-007
No. 21253 Jurisdiction = La, Quinta
Owner NameGerard J. Gadder. Permit #0011-236
No. , 50=920. Street Calle Obispo Log #-
City La Quinta zip . 92253 ,Study Area
Tract # Lot #' Square 1179btage. .482
Type of Development Residential Addition, No. of Units 1
Comments Addition is a bonusroom.
At the present time, the - Desert Sands. Unified School . District "doesnot collect fees on garages/carports, covered
patios/walkways,-residential additions undee500 square feet, detaci4d accessory structirds or replacement mobilehomes. It
has been determined the-aliove'named owner is exenipt from:pay►ng school fees atttiis 'time due.to the following reason:.
Residential Addifi n 500: Sq -Yeet 'or Less "
EXEMPT
This certifies that school facility fees imposed pursuant:to Government Code 5308004 in the amount of
0.00 X 482 or $ '0:00 theproperty�listed above1nd that building.
permits and/or Certificates of Occupancy foithis square footage in this proposed project may ;no`w=be,issued
Fees Paid By N/A - Gerard Gander
Telephone 760-564-2467
-Nam: on the;check
By Dr. Doris Wilson
Superintendent '
Fee collected /exempted by Annette'Barlow Exempt
Check No.
Signature
NOTICE: Pursuant of Assembly Bill 3081 -(CHAP 549, STATS.,1996)this,will serve t6notdyyou that the 90day approval penod inywhrchly u,may protest the fees or other payment identified
above will begin to run from thei
OWNER ?BUILDER INFORMATION
Dear Property Owner:
An application -for a_building.peimit has been submitted in your name listing yourself, as the builder of the property
improvements specified.
For your protection .y9p'should be aware that as "Owner`%'Builder" you are the,responsible party of record on such a
permit. Building perrhitsare 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 b`y law to'be licensed and bonded by the StaWof 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.
If you plan to-do your own work„with the ezcepiion of variuus,trades that you plan to subcontract, you should be
aware of the following information for. your benef t 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 of 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 in employer and you are subject
to several obligations including State and Federal income tax_ withlibldcng ,.;federal' social security taxes, worker's
compensation insurance, disability insurance costs and unemploymentcompensation contributions.
There may be financial risks for•you'.ifyou do norcarry`put these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your: obligations under"yederal Law, contact the Internal Revenue Service (and, if
you wish, theU.S. Small,: usiness Adtninstration). For more specific.information"aliouryour obligations under Stare
Law, contact the Departmeni of Benefit'Payments and -the Division of Indusirial-,Accidents.
If the structure is intended'for,sale,_ property owners, whoaare not licensed contractors are allowedto perform their
work personally or through their own."employees, without a licensed contractor,or subcontractor, only under limited
conditions.
unlicensed persons professing to be contractors is to secure am "Owner/ building
A frequent practice of
permit, erroneously implying tfiat -the property owner isproviding his. or her ov✓n', labor and material personally.
Building permits are notc 4' ired iot;be signe8` by property owners unless they are performing their own work
personally.
Information about,licensed,con t actois 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 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,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(76 777-7012
F_ 0) 797-7
{
OWNER'S SIGNATURE /DATE.
So.9tZD C� 11Ma_ 8i- j
PROPERTiY ADDRESS'
PERMIT NUMBER(s)