0212-084 (BLCK)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:
V) 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' his reason .>
Date Signature of Owne�.. ms's
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 A1,l.S5?1Tg i2d$ Cf? Policy No. 36"109m28'M60
(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 for inspcfion purposes.
Signature (Owner/Agen •rte .F� .�F - `£ 1 iDate
.� .7—
BUILDING
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0212-(iceTRACT
$866.00 99
JOB SITE APN
ADDRESS -769- CAUX
C7 6A '43 !� - s b�
sa .
OWNER CONTRACTOR / DESIGNER / ENGINEER
RIGODER'ii} & ANNA REYE 3 OWN R I iSLITtIDEIR.
5 1943 CALLE TORRES ORUNDO
t OAC'kTL7 ,A CA 92236
USE OF PERMIT
OFNE RAL 93UIWING
40 LF. Y OARDEN WA1,.1,, CITY S`Y.a'►1'J77A RO
5 FT. WALL 40.00 LF
i'
FSTM IIED CUA r OF CC?.t�`�r'":�`RUCV.1110H 866.00
CONg-TRUC`IION FEE 101-000.418.000 523.0
O
SEC 13 2002
CITY OF QU%%TA
FINANCE DEPT.
SUB -TOTAL CCN UCTION AND PLAW. CHECK $2.3:00
MUMS PRE-PAYD PMRS $0100
RECEIPT DATE BY DATE FINALEDINSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs . Q 3
Electric Bond
Footings - yT
Main Drain
Bond Beam 1 _
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
COMMENTS:
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)
' .OWNER/ BUILDER .,!NFORMATION i
Dear Property Owner: t
An application for a:bwilding permit has been submitted•in your name listing yourself:as ihe.builder of the property
improvements specified: r t r
For your protection -you should be aware that as s Owner/:Builder" you are the"responsible,parcy of recoid on such a
permit. Building' permits are not required. ,,to be signed by propeity Hers unless'ihey are personally; performing their
own work.'If your work,is'betng performed bysomeone pthd than yourielf,�you may proiect'yourself from possible
liability.if that person'applies,foi'the proper permit in his or her :name ,
Contractors are required?by law 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, lawco.,put their. license number on'alI permits for which they
apply ,. .. �,
If you plan -to do your own -work, wuh the' exception,of various trades that you.plan to subcontract, you should be
aware of the following information for your`benef tandoprotecion:
If you employ or otherwise engage any'persons other than your immediate family, and4he work (including materials
and other. costs) is $200,00 or.'more'-for the en iretiproject, an, disuch "persons are not licensed as contractors of
subcont"factors, then you may be an employer. ;
o
If you are an employer, you.must'regtster'with the State and Federal Gov'erilm'6it'as arv,.emploftr-and you are subject
to several obligations including State and'.TederalArk6m'e tax4ithholding,{f ederal'soual�secunty taxes, worker's
7 compensation insurance-disabi ityinsurance costs�and.unemploymenrcompensacion concnbutions.
fM
` There may: be financial risks,for you if you. do noc`car_ry out _ythese obligations, and these risks are especially serious with
'respect to.:worker'scompensatton'.insurance,r .
For more specific information about:.your obligations under Federal Law, cont c`t'Alie Internal Revenue Service (and, if
you wish, the U.S.- •Small"business Adminstrauon) .For more specific in formation•abouf your obligations under -State
5 41 - 4. �Y� r t fi
Law, contact the Department ofBenefit:Paymeritsand the:Dtvisi_on oflndustrtal Accidents.
If the structure is intended'for sale.; property owners;aho'xare riott.licensed7contractois.aie allowed to,perform.their
work personally or through their• own employees; �hout a licensed contractor or'subcontractoi, only under limited
conditions.:' ,
.j
A frequent_ practice of unlicensed persons professing to be contraciors`is to secure an ' Owner/Builder" building
permit,; erroneously implying that4the.pr6perty,owneuis''p oviding his or her,owri labor and material personally.
Building, permits arernot required,'to 45e sagii 4' by property ownersJunless they are performing 'their own work
personally. Y
•Information about licensed contractors may be obiained`by. contacting the Contractor's' State License Board in your
community or at•1020 N. Street .Sacramento, California 95.814: s, w
Please complete and return the enclosed owner builderveificauon form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the'verification is Burned: ,
�.. ;,.
Very truly. yours,
CITY OF LA QUINTA•,
' DEPT, OF BUILDING AND SAFETY
78-495 Calle Tampico s
La Quinta, CA 92253
(760) 777-.7012
FAX (760) 1}
y• -
O ER'S SIGNATURE/ ATE .
PROPERTY ADDRE SS' ;- `e +
PERMIT NUMBER(;),Z AAr - rr ;
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