0109-213 (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).
( ) 1, 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 reason y
Date 43' _:];a .r rr t Signature of Owner
M
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
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 thE.' the above information is
correct. I agree to comply with all City, and Stata laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection'purposes..,.
r�
Signature (Owner/Agent) -�'�• - �'�� Date �%'- •.-�'=% °"`
BUILDING IT PERMIT#
.PERM_
DATE =` . _ .VALUATION LOT ()109-213 TRACT
JOB SITE
APN -
ADDRESS
SN 45D pp E QDp9
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LAQUINIT s ('.�cd"A '.-253
USE OF PERMIT
F -STB f ±'D C09T OF L:ON'97IRTIM011T
DQD,+ f9
SxIXAt9Fr1i" 01 FIM 319WAR ] 02 _000.41110.000 SAW
• ;4
1 U__
JLi-�
SEP 2 ri 2001
CITY OF LA QUINT#,
FINANCE DEPT.
LOS PRE -PAM i ITO
X0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 4
Underground Ducts
Forms & Footings I
Ducts
Slab Grade }
Return Air
Steel ►
Combustion Air
Roof Deck I
Exhaust Fans.
O.K. to Wrap I
F.A.U.
Framing 1
Compressor
Insulation }
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wali Firewall I
Exterior Lath I
Drywall - Int. Lath }
I
i
!
Final
Final ►
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs }
Electric Bond
Footings I
Main Drain
Bond Beam i
Approval to Cover
I
Equipment Location
!
Underground Electric
i
Underground Plbg. Test
Final }
Gas Piping
PLUMBING APPROVALS
+
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out }
Equipment Enclosure
Shower Pans }
0. K. for Finish Plaster
Sewer Lateral ]
Pool Cover
Sewer Connection 1
Encapsulation
Gas Piping
Gas Test I
Appliances
Final
I
COMMENTS:
I
1
Final I
Utility Notice (Gas) }
ELECTRICAL APPROVALS
Temp. Power Pole }
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures }
Main Service I
Sub Panels I
Exterior Receptacles
G.F.I. ]
Smoke Detectors I
Temp. Use of Power
1
Final !
Utility Notice (Perm)
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.nor.required to be,signed by property, owners unless they ire'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 -St ate of 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 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 licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you. must reg ister"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 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.the Internal Revenue Service (and, if
you wish, the U.S. Small 'Business Adminstration). For Mori 'specific informatIionwaabout your obligations under State
Law, contact the Department of Benefit'Payments and the Division of Industrial Accidenis.
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
`t 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 hei�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-buildervertfication forrn•so that we can -confirm that you are aware of
these matters. The buildingpeimit'will norbe 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
(760)777-7012
FAX: (760) 777-
O S GNATU ATE.
/,50
PROPERTY ADDRESS
1�1o9- a13:
PERMIT NUMBER(s)
COACHELLA VALLEY WATER' DISTRICT
ASH -RECEIPT DETAIL
0 9 45,
Received From:V VA -
—Date:
4C
Address:
Lol(s), Tract
Account No.
G.A. Code
Service Address
0 Meter(s) $
0 Service(s)
0 Backflow(s)
0 House Lat6ral(s)
0 Detector Check(s)
0 Meter Surcharge
Sanitation Capacity Charge
0 W.S. B. F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
4.
0 Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
t.
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
TOTAL
2 \—C)
Remarks:
azovito:
V Cash Water Service
Check
Money Cashier
Order CVWD-438 (I 1 /89)