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9612-121 (PLBG)- -� 'LICENSED CONTRACTOR DECLARATION I hereby affiriri'uncle! penalty of perjurythat I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals i:ode, and my License• is in.full force and effect. Licens{e # 'I; Lic. Class' "i-; ' ' Exp. Date .1• , 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 ieason: ( ) 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). O I am exempt under Section B&PC for this ; ason Date ^1 47 Signature of Owner 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. O 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, L.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.$100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth .on his application: ' 1. Each person upon whose behalf this application is made& each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to,.&'shall; indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit' issued as a result of this application .becomes null and void if work is not commenced within 180 days from date of .issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. ' I certify that I have read this application -and state that the above information is correct. I agree to comply with all City, and State laws relating to the buildIry99,, construction, and hereby authorize representatives of this City to enter up8rt,� the above-mentioned property for inspection purposes. Signature (Owner/Agent) Date PERMIT # CONTROL # BUILDING PERMIT 9612-12.14526 DATE f �(j VALUATION S'},000.00 LOT-_ . ,' TRACT . . ADDRESS 77-`920 �. ALL1 ..NODAL" JOB SITE APN OWNER CONTRACTOR / DESIGNER ENGINEER Aj[ 7T:t't fttti6tt�j'ta ...44,1,��.j�#{0..1, 177:-11p1.Ck - l�lt!tT�7YA'k1 c31^� SI /Y .�.l t• is L g* ��+f LA QU!IVTA CA 92753 CBMI USE OF PERMIT '(����,++��r���fr 4.13��'i' 1 �\s .��+4+M.1.�. �;1?\• V4.t,)4�..i•�lm �I'D.t ��� ' - . _ }:,`iiv'i't•Zti�."%'ti�$s:aiJili'.e' ,ifiit,),�itt.i.;; cis Jpfl000 P11)KBANO W 'W. yi ER 101,-OW19-040' f ;r,'EJ. r("i3t :�3:1Ni �'3:fl�tti�� ;.d ¢i>f �.. $39,00 r i.,ES;S.r :�.RE.-i'Ac%.rt'EES $0,00 }' 1 a 'R'tB $'l [,J']k doh 1' .'OFai)iJ:B NOW. e") DEQ 19 1996 / / RECEIPTV/I�. eTE :. BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Fc'ms & 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 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: O/ ©v �, 174e Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole p 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) • vWM%IncLLA VALLLY WATER DISTRICT CASH RECEIPT DETAIL Received From: RC2 "9 ;"i'4 �_��+}-- I Address: Account No: • 'L- 4[ , Service ; .�, �( l2- 6"e, e—ot , Date• .�1. L_o (s) i Trac • Address " ❑ Meter(s) ❑ Service(s) G.A. Code cc i �. ❑ Backflow(s) f � { ❑ House Laterals) ? f. ❑ DetectorCheck(s) ❑ Meter Surcharge L tH`Sanitation Capacity Charge _ _ i ❑ W.S.B.F.C. i { ❑ Temporary Construction Meter ❑ Turn on Charge f u ❑ Uncollected Account - Name ' ❑ Inspection Fee - Tract - Fee - ' ❑ Plan Check Fees Water I Sewer - { Tract - 1 ❑ Bond Payment - A.D. - Bond Assmt. t ❑ Customer Deposit j i ❑ Other Remarks: TOTAL g r ( ❑ Copy to: Cash i Check Money Water Service Order Cashier CVWD-438(11/89) ""+t',�:+++t+t-i'tie"4�""aib-sr'fs.c-^"'�.'i�`�Y!,r'�;•.�'�';,�-��1'"'�`J��``��+�r��"�y"��'afiY�'a`r^'y"�.c�`�"'t`r`�"�`�"r;..-...g-�x.� ...... 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 maybe 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 security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There maybe financial.risks for you if you do not carry out theseobligations, 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.-Slall 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 Coniractors' Siate 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 78-105 Calle Estado La Quinta;. CA 92253 (619) 564-2246 FAX: (619) 555664-556/6117 OWNER'S SIGNATURE /DATE ' PROPERTY ADDRESS PERMIT NUMBER(s) F .