0107-205 (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 .17
t 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
mpensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7044, Businesd;A Professionals Code).
( ) I, as owner of tho"property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professio als
Code).
O I a tempt` nder Section B6�or this reqsDate " !' " �' Signature of `nerd A
WORKER'S C9MIPENSATION 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 shobecor
subject to the workers' compensation Islons of Se fi,i� p the �r
Code, I shall foXhwjth comply Wjt�h a W�isions. !.<I f 9
Warning: Failure to secuYe Workers' Compensation coverage is unlawful and
shall subject an employer to criminal pena"fties 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 appiicaton 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 the building
construction, and hereby authptjzq representatives of�this Cit�o enter upon
ned
the above-mentioprop8�I.t spection ll f
Signature (Owner/4n' - ' F' rl` f Y'ri ate
BUILDING PERMIT PERMIT#
DATE VALUATION 1' LOT 010 J-2AjS TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIQNER / EN (NEER
0.l::l` 1KIII G l�.u�affq
'19675 COYTIZZ LIN,
1A Q-U.DffA CA,
MIX
USE OF PERMIT
FidWIING'-
SKfP7IC A.13A3+fDi7(tf8PAFNT$3,J?.'W9R HOOKUP
Vr'af,i.f1`MC,lF
E vt`, 'MIA. COST" OF i"0]!ILb".MI"�i�'.�A0N
FFKtArf 3a' i ttl:t't/WAk?' Y
101 -WO -419.000 $30-00
_WWW 'r
I If� �II
JUL 1 9 2001
((��Y �'* .p�•�sy�p � f �,T� /� y� 1 y.�
YD l-a'i L/4A1� i4oN1 5�.+�\.. ).Aw�J.7 i'l�bb .fX lLLy\''Fjlt` L.S'L
yy4il. alV
RECEIPT
DATE /
BY
DATE FINALED
INSPECTOR
MSPECTM RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BQ.DDIL UNG 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 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final FOODS e SPAS
SLOCKWALL. APPROVALS Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
pLUMUNG 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 Z �—
Final
COMMENTS:
Final
Utility Notice (Gas)
ELEC` MCAL 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)
; PAMMER PUMPING INC. JOB INVOICE .
P.O. Bax 2448
CATHEDRAL CITY,.CAL-IFORNIA.92235-2-448
17ani zsn _ 7ddA.
QUANT.
�-
(760) 321- 7448_-�`i
PRICE
CUSTOMER'S ORDER. NO'..
DA 'O D
Gallons .
-
ORDEWTAKEN BY
DA;E PROMISED ❑ A -M.
Pumping Fee per 1000 .gal.
r °'
J
y -�(eErww
BILL TO
PHONE
ADDR
Dumping Fee per 1000 gal.
�—
i
HELPER
JOB NAME AND LOCATION r
Out of Arealee
WORK
DESCRIPTIO
WORK
r
�DEXTR�A
�
Size System:
QUANT.
DESCRIPTION OF MATERIAL.USED,
PRICE
AMOUNT
Gallons .
I
Pumping Fee per 1000 .gal.
r °'
Dumping Fee per 1000 gal.
�—
Out of Arealee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON.
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS ®
HELPERS @
LA80R
I hereby.ac,knowledge the. -satisfactory
co ietion of the above.described work:
i07AL LABOR
TAX
SIG_ E -
DATE COMPLETED
�" ��
TOTALS
COACHELLA VALLEY WATER.DISTRICT
CASH RECEIPT DETAIL
Received From:
Add -roes: T4 - (1i —I 1�15
I. Account L
Service Address
0 Meter(s)
0 Service(s)
0 Backflow(s)
0 House Lateral(s)
0 Detector Check(s)
0 Meter Surcharge
$B" Sanitation Capacity Charge
0 W.S.B.F.C.
0 Temporary Construction Motor
0 Turn on Charge
0 Uncollected Account- Name
0 Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment'- A.D. --Bond
Assmt.
D Customer
0 Other_
Remarks:
e6py to:
0 8 4,`35 2,
Date-
Trct,': 11.1
G.A. Code
TOTAL
WaterService
Cashier
CV.WD-438(11189)
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 notxequired 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 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 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 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
PROPERTY ADDRESS
PERMIT NUMBER(s)