0104-051 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm u rider penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the BusinE3s and
N W Professionals -Code, and my License is in full force and effect.
C :D ch License#► Lic. Class Exp. Date
Ll l
Z Date Signature of Contractor ` \`
OCID
ti
U OWNER -BUILDER DECLARATION
LU H LU �` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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 oroffered 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).
c'`) O I am exempt under Section , B&P.C. for this reason
143
N Date Signature of Owner
ON
G7
(LQ . WORKER'S COMPENSATION DECLARATION
p Z I -hereby affirm under penalty of perjury one of the following declarations:
53
H O O 1 have and will maintain a certificate of consentto self -insure for workers'
X W L: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
M Q U () 1 have and will maintain workers' compensation insurance, as required by
Q U Section 3700 of the Labor Code, for the performance of the work for which this
Il LO •H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
' ob d
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,
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 1 should become
3 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 forlik 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 pursuantto
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. building
construction, and hereby authorize representatives of this City to enter upon
the. above-mentioned property for..inspection purposes.
Signature (Owner/Agent) '�+" '+<•-z,, '�- Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Qjy,(jr�.'I TRACT
-JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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OWN?)Wk3U1L:t ER
Lk QW071-A CA 92253
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USE OFPERMIT
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1''Mtif:�''jf��t Y)' NOW
"LAQUINTA
51.0(D
PT Y
DATE FINALED
TNSPECTQB
NSPECTM RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
SULDWG APPROVALS MECHlAN=L APPROVALS
Set Mks Underground Ducts
Forms & Footings Ducts
' Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
0. 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
COOLS a SPIAS
�L�OCG�Cf�'lALL APPROVALS steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
(Final
Gas Piping
PLUMSQNG APPROVALS GasElecTeric 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:
Final
Utility Notice (Gas)
ELECT=AL 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)
T4'!t 4 4 Q"
78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253
TELEPHONE (760) 777-7012 FAX (760) 777-7011
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/ 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`personsother 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 tol 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 buildingpermit will -not -be -,issued until the verification isreturned:
Very truly yours,
i
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
la Qiinta, CA 92253
(760) 77 -7012
FAX (76 011
4-)n vJ
OWNER'S ATURE/D TE
S?— 6G -5— Coer T e 77—
PROPERTY ADDRESS -
IQ I O - 0 5_�
PERMIT NUMBER(s)