9607-014 (RER)LICENSED CONTRACTOR DECLARATION
U) 1 -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
(V W Professionals Code, and my License is in full force and effect.
O Z) ch License # Lic. Class Exp. Date
C) LO
W
Z r Date Signature'of Contractor
r O ,
C) °� OWNER -BUILDER DECLARATION
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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).
LO () I am exempt under Section B&P.C. for this reason
N ate � '� �'r Signature of Owner
Orn {/
Q WORKER'S COMPENSATION DECLARATION
CL
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LID - O () 1 have and will maintain a certificate of consent to self insure for workers'
X W Y= compensation, as provided for by Sectiop 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O V Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier &.policy no. are:
It Z Carrier -Policy No.
oD 5
�O •
J
(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
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 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 building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature- (Owner/Agent) Date
• � PERM T# °°NTR°`#
BUILDING PERMIT
_,607-x11 . 3669
DATE VALUATION LOT TRACT
719196 S-14.433.80 .
I JOB DDR SS t^4d0 �AX.,LU ILO�ILO APN 769-115-003
OWNER CONTRACTOR / DESIGNER / ENGINEER
3.is;�C7� BSc I,,t)[3fi1i►i?�+ �fiN't",','E� 7 • � •
'S141Gr'ALL8 ILOILO
LA QLi"I,N'! A. CA 92,41
USE OF PERMIT
26-6 SO. FT. kf?A10EWADDIT.1ON
TRACT. COWIITRJC'" iOW
ONNINER-i3(!'ILLIPM
'!66.00 4(
"TINLATIED COST OF 4.:ONNT,93:U010
Pf'N��I.C'.�'ti�l+:lk.N�If4��L�ARY =
PLAN CR CK''".h�
$103.30
E1,.l;C'1 ICAL FE
10; -000-420-000
524.31
STOW,' MOTJON ra-RF;,Sln
101-+000441-000
x:1.94
ECeitiMCAL n' E,
)£11,0?H?-4?1-000
Ste
93Lt1.1la1N4%.i �.
10.1=( M_1.9 -(3W
CUL9
,4,443.84)
SUB-IMAJ. i ONSTRUCION AN1) PLAN. CHECK $347.05
LESS l�.t-t�AfT)AES $0.00
• ] �.y y res; y q�*ry: n��r ,�e7q�, NOW
. .52�i d•�,AL F' JL'al4lY IT FEES ES IAJ'e',.�- 1lfkli�T - � S347.05
RE EIP ? • DATE`% '1). BY , !'y 2 / DATE FINALED INSPECTOR
'.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs A I q 4 14Underground
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 jr-11, 7 W
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 APPROV4LS,
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
eater Final
Water Piping
P tubing Final
Plumbing Top Out
Eq •pment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool over
Sewer Connection
Encapkulation
Gas Piping
Gas Test
Appliances
Final •
COMME TSAA:,
/4 /4
G/1j/
T
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power p
Final
U>:* Notice (Perm)
Notice:
Document Cannot Be Duplicated
Date 7/22/96
No. 14720
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 769-115-003
Jurisdiction La Quinta
Owner Name Jesus & Lourdes Benitez
No. 51410 Street Calle Iloilo
City La Quinta zip 92253
Permit #
Log #
Study Area 115
Tract # Lot # Square Footage 266
Type of Development Residential Addition No. of Units 1
Comments
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 or
replacement mobilehomes. It has been determined the above-named owner is exempt from paying
school fees 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 Government Code 53080
in the amount of 0.00 X 266 or $ 0.00
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 N/A
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson Exempt
r
'elephone 73 43-5387
r in
A� V
;, xr
$0.00
Check No. N/A
Signature c Qt A A 0 nn o �f 9 A A n A AA,^_
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy- Accounting
TELEPHONE (619) 564-2246 FAX (619) 564=5617 ,
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 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
DEFT. OF BUILDING AND SAFETY
78-105 Calle Estado
La Quinta,. CA 92253
(619)564-2246 7
FAX: (619) 5%5617
OWNER'S SIGNATU /DATE .
w
PROPERTY ADDRESS
PERMIT NUMBER(s)