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0104-264 (RPL)LICENSED CONTRACTOR DECLARATION U) 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 N W Professionals Code, and my License is in full force and effect. O 5 M License # Lic. Class Exp. Date LU t� Z r— Date Signature of Contractor 6 OWNER -BUILDER DECLARATION Hd I hereby affirm under penalty of perjury that I am exempt from the Contractor's Q_ License Law for the following reason: `. Z_' I, as owner of the property, or my employees with wages as their sole t� compensation, will do the work, and the structure is not intended or offered for j sale (Sec. 7044, Business & Professionals Code). I ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). O I am z mpt u{�der Section B&P.C.�for thi§ reaso • CV Date '� -��1 Signature of Owner � s d Q, ---"" CNJ WORKER'S COMPENSATION DECLARATION p 2 Z I hereby affirm under penalty of perjury one of the following declarations: v% * r O () 1 have and will maintain a certificate of consent to self -insure for workers' X W Y- compensation, as provided for by Section 3700 of the Labor Code, for the 't�1 Om J Q performance of the work for which this permi' is issued. Q U ( ) I have and will maintain workers' compensation insurance, as required by Q U Q Section 3700 of the Labor Code, for the performance of the work for which this i►' d 0 permit is issued. My workers' compensation insurance carrier & policy no. are: 'IT Z Comer Policy No. O J (This section need not be completed if the permit valuation is for $100.00 or less). IX 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 j;( workers' compensation laws of California, and agree that if I should become !� i _ subject tche workers' compensation proyis ons of Section 3700 of the Labor i,� 3 Code (I shall fortrhwi comply with th`osed,p'rovisions. t Date: vl,-!�Y)0 Applicant, �r,✓J�iLb - r - Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fine'!�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. z. IMPORTANT Application is hereby made to the Director of Building and Safety 0CL oL 44for a permit subject to the conditions and restrictions set forth on his application. wr"r 1. Each person upon whose behalf this application is made & each person at + whose request and +or whose benefit work is performed under or pursuant to �\ any permit issued as a result this applicator agrees to, &shall, indemnify �y Vip &hold harmless the City of Laa Quinta, its officers, agents and employees. Y:: 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 yys permit, or cessation of work for 180 days will subject permit to cancellation. 1 certify that I have read INS application and state that the above information is r..* • 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 propei y,forinspecticn purposes. Signature (Own r Agent 4 L/�, ��Date_.U r, t t BUILDING PERMIT PERMIT# DATE VALUATION LOT ti^2 TRACT ) y�+� ��yy� ttt� WEA7llllr loo JOB SITE �"Y"- APN ADDRESS 7&80 IfOL N C'M .: IE OWNER CONTRACTOR/DESIGNER/EN("INEER XR4 & CAROL SHOCKEY C' MER BWLDER 78-605 340 AN C11ZC`_A LA QUIN`t'A CA, 92253 CBL9 USE OF PERMIT PCOLMP A ONLY, I.f1;4tMas', ARRIERa4.24RE TO 8Z OPERATIONAL PRIOR, TO iii -CAP, P.kF 1,1,A.917R 100S'P,f'Tit?K POOL,! ND/OR SPA A09010 LS COY -F �F.ls �:Q S"MIXI :I:ON Zi?,DtJ#i.l?(i 'yyy�,��gp}}' `e yyy1qy��x�7 �y�rg y`y��'p, yY'ti9�ilSN1,13) FiRr.TXL1� 1111 �6J.�.d• CY �JJAVd�1Md:SE.f PLAN CHECK WE - 103.000-4.39,3113 5;:1+1.55 t::iaP6':sTRU'C;TM F19Z c, 101-•0M)-418.000 $207.00 MECHANICAL ME -- I'c )L 101 -000-421 -ODO $24.40 MK. 'Tbfi: CA.t. VEX n- POOL 101-000-420-000 $45.00 PLUM.BiNC FRE --100,T 327.00 G v $0.00 LESD 1+KI+rVAI'.© MRS APR 2 5 2001 ' 1 1 0. ff PEEG DUE NOW CITY OF LA OUINTA FINANCE DEPT RECEIPT DATE ! BY DATE FINALED INSPECTOR - • • • •_ _• Y_... ... . mow. • . s • o • ►-• a ► ► • ----- • • • , • • ► • • • •_ •••.�: __• • • • • i • _ -- -- 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 Electric Bond Footings Main Drain Bond Beam Approval to Cover Final PLUMBING APPROVALS Equipment Location Underground Electric Underground Plbg. Test Gas Piping Gas Test y _ ! s Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Sewer Connection Pool Cover Encapsulation Gas Piping C:& ytj _ _%L (AV_:b4_ Gas Test Appliances Final COMMENTS- �1�18•�r t j�2— C.t�''�' 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) i� SIAUCI«C/ R4 ST owvt 1-�-�6; Noes r � CITY OF LA QUINTA SUB -CONTRACTOR LIST K JOB ADDRESS 7 an_gO� A/0 � C(ERMIT NUMBER OWNER BUILDER [�✓" �`' [��� This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on t1his list or their employees are authorized to work on this iob. Anv changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance of building permit. For each applicable' trade,. al I information requested below must be completed by'applic.arit. "Ori File" is notan acceptable response. ::>::>::; .. _ ::::::;;::...::.; ;::.;;::: .... ............. ... «s>%: >; _........ Cit .:Busness.License Company Name Classification License Number Exp. Date Carrier Name Policy Number Exp. .Date se Number er Licenseen Exp.. Date (e.g. B C-81 1xxIxx xx1 1e. . State Fund CaIComP1A Varies) Format 1 xxxx/x x1 xxxx 1 1 xx xxI x x 1 EARTHWO:RIC(C:=1:21:€'`< _ 48 FRI4MINC:: ..::.:..::.,::::.:.1::::: CT..­S:-..EFL>: C._5:11> >: 5TRU:::.:�::.:.; MASONRY: (C -291`.<':<r<?: PLUMBINQ C :=361::::'`»::>;' LATH;>PLASTERfC�351<' - � .. ' DR M ::ELECTRICAL1 .ROOFING:;(C.:3..:::�.»>;:.;::.;;;;;::.:;:::. EET METAI'IC`... 1',, <:' : , X .:.. 5 IN INSUI ATION`:(G:-21. ` . .. SEWAGE; DISp 21>«<? ..........( <TIL&f,.., .CERAMIC .. :C ARINETS: FENCIN( iita '...3 LANDSCAPING IC Z71 (✓t C ' i.► 1 o T T4 FAN Oo X36" G1 G �Z� Ni.T 1� 4/7 : y i CITY OF LA QUINTA SUB -CONTRACTOR LIST 'JOB ADDRESS ^' PERMIT NUMBER OWNER :BUILDER This form shall be posted on the job with the BuilAina Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance of building permit. For each applicable trade, all information requested below must be completed by applicant. ",L)n riie, is not an acceptaoie respuimu. _. ..:..;:: <; Business License.;.:: .......... Insurance ...:..:.. Cit : . Wotkers;.Com ensation < ..:... ntractor............:.:..::....:.......:::.:..:::::::.::::::::.State::Contractor... s:.License.:::::::::::::::::..:.:::...:::::::::.:::::::::..::::::::::::..... >::» Ttade>:/:;:Classif icat�on..:.:... ............................... .. Exp. . Da to License a Nu mber Exp. omP1 1Format Vcries1 xx/xx xx1 1xxxx1 x x/ xxI xx 1ComPanYName Classification License Number Exp Date Carrier Name Policy Date 1e.9.A B, C-81 1xxxxxx1 1xx/xx xx1 1e.9 State Fund, CaIC f%Aw:: 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 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 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 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 register with the State and Federal Government as an employerand 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 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, without a licensed contractor or subcontractor, only under limited 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 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 form so that we can confirm that you are awarepf 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 (760) 777-7012 FAX (7;0) 7AA 11 OWNER'S SIGNATURE/DUE ez" PROPERTY ADDRESS 0 1 0,4-ZAT PERMIT NUMBER(s)