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0212-044 (AR)LICENSED CONTRACTOR DECLARATION U) I hereby affirm under penalty of perjury that I am licensed under provisions of H 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. ODM License # Lic. Class Exp. Date L r W rZ0� Z ti Date Signature of Contractor Oti J U OWNER -BUILDER DECLARATION HUJI I hereby affirm under penalty of perjury that I am exempt from the Contractor's CL co License Law for the following reason: Z ( ) 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). NO I am exempt under Section B&RC: fo'r;this.reason rn Date : _ a c% Signature of Owner - d Q WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: n H O () 1 have and will maintain a certificate of consent to self -insure for workers' K W u' compensation, as provided for by Section 3700 of the Labor Code, for the 7 J Q performance of the work for which this permit is issued. I have and will maintain workers' compensation .insurance, as required by j U. Q Section 3700 of the Labor Code, for the performance of the work for which this L rn H permit is issued. My workers' compensation insurance carrier & policy no. are: It Z Carrier Policy No. Cb g (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, 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 3 subject to. the workers' compensation provisions, of Section 3700 of the Labor Code, Irshall.forthwith comply witKthose provisions. , 4' Date:l —r''' f Applicant f 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 r 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 Ouinta, 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 inspection purposes. Signature (Owner/Agent) f r" .r '= ' Date ~ PERMIT Y BUILDING Jam... ,PERMIT ` •� f1"�:�7,13w1�E DATE VALUATION LOT TRACT JOB SITE APN ADDRESS :L'Or 02jl ),, 4�+i`]S1�As OWNER CONTRACTOR / DESIGNER / ENGINEER 54•:121 A\TFYffU)A(fiN:fX,,' L.A. QU114TA CA 92253 USE OF PERMIT RYOMEN111 , 41)1)f_11014 14'71V A0Llf°t`10A RX,,`M02:*l,1'U APP4;OV Iii) P1,414S EVER07 VA,14.'S, RES. isKAgtif E11 (0,018,00 is ADDITION 147.00 SF :S'X'MWIXT) (11093' OF C (_)NS.E RUC1'A)ffJ 7�,f1F3il.3.0 PladWIT 1i°ry, suml D.'Ry PLAP CHECK YH 101.000-'!39-:31 tz, $343,48 CCYNSTRUCTION FEE 101-000-418-000 ELWTRICAL, RE 101.000-420-0100 STKUNQ MOT 1014 Flt , - RIfS]ID 10 1 -000- 44.1-W, ) SUB- (Y,I AL C ONUIM 7(, L01`I MEL) MAt3 7i .CK TOTAL y ,,[4-(�Ani,I,7 (�{��1.,[pt6e� <_. 7 RECEIPT DATE ; j ' ? {,7BY DATA FINALED NSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs - 03 Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O. K. to Wrap F.A.U. Framing U Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drvwall - Int. Lath i — Final Final BLOCKWALL APPROVALS POOLS a SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test incl 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 ,Seaver Lateral Pool Cover 'Sewer Connection Encapsulation Gas Piping `.Gas Test Appliances Final 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) COMMENTS: OWNER/BUILDER INFORMATION Dear Property Owner: An application fora building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should ber 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 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 outthese obligations, and these risks are especially serious with respect to worker's compensation insurance. For more speck 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 (760) 777-7012 FAX (760) 7-7011 • OWNER'S SIGNATURE/DATE It PROPERTY ADDRESS D Z(Z- o PERMIT NUMBER(s) _ CITY OF LA QUINTA SUB -CONT AICTOR LIST' J JOB ADDRESS_ �;40�Ll A0L C -Ori - PERMIT NUMBER OWNER a'Z/4&_E0Z14 BUILDER SA4f;;' 8 ka This form shall be posted on the job with the Building inspection Card at all times in a conspicuousID ace. Only persons appearing on this list or their employees are aut 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 idance of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response. Trade /Classification:, on rac or .:.. ..... . , G. . t . t.. ; .: .;: Stete;:Contractor.;s..L�cense >::_ :::.: Workers..Com ®nsa 'on l" :'' ' ti _.....nsurance a ; 'Crt `Bus�ness:,Gcense Company Name Classification (e.g. A, B, C-8) License Number Exp. Date (xxxxxx) (xxlxxlxx) Carrier Name Policy Number (e.g. State. Fund, CalComp) (Format Varies) Exp. Date (xx/xx/xx) License Number (xxxx) Exp. Date (xxlxxlxx) EARTHWORK (C 12) AIIA CONGRETE';(C 8)� - FRAMING .(C 5) » N STRUCT STEEL (C 51) N MA,SpNRY IC 29) N PLUMBING (G 36) V�IJ 3 ��'� !'�dTt �Mf'. � � �- G�i� �G� . LATH PLASTER (C;35) :�' DRYWALL C-9) Q�j�. Me Sp M rhe 1LECT 64 PA HI DuAiV 0603- U-) ROOFING (C 391 ae)A/ SHEET METAL (C -431C. �� A G A . �- FLOORING. (C 15) D�/v �� GLAZ)NG (G 17) h � INSI�IATIQyN. lG Z) • . /i » SEWAGE DIS (C-42)Gu�G� G AI PAINTING IC 331 AA'' CERAMIC TILE (C 54) Dr%%I. F'ENCENO IC=131.;,,,.• �.;.:;..:::: . •LAND.SCAPING'(C7.). A POOL` tG 53)N-15Iv / IN Comments 147 SF addition/remodel At the present time, the Desert Sands Unified School District does not Collect fees on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping,. cooking, eating or sanitation) .or replacement mobile homes. It has been determined that the owner is exempt from paying schooffees at this time due to the following reason: Residential Addition 500 Sq Feet or Less EXEMPT This certifies that school facility fees imposed pursuant to Education Code Section 17620 and Government Code 65995 Et Seq. in the amount of $0.00 X 147 S.F. or $0.00 have been paid for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. Fees Paid By EXEMPT - Karl Schiersch Check No. - Name on the check Telephone Funding Exempt By Dr. Doris Wilson Superintendent Fee collected /exempted by Monica Guillen 0.00 Payment Recd Over/Under Signature r NOTICE,- Pursuant to Government Code Section 66020(d)(1), this will serve tomotifyyou that the 90 -day approval period in which you may protest the fees or otherpayment identfied above Will begin to run from the data, on which the building or installation permit for this project 1&lssued, or from the date on which those amounts are paid to the District(s) or to another public entity authorized to coiled them on the Districtfs) behalf, whichever is earlier. NOTICE: This Document NOT VALID if Duplicated- Embossed uplicated Embossed Original - Building DeparimenUApplicant Copy - Applicant/Receipt Copy - Accounting