9706-146 (PAT)` LICENSED CONTRACTOR DECLARATION., --Chapter 9 (commencing with Section 10,00) of Division 3 bf the Business and
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],hereby affirm,under penalty of per -jury that I am licensed under provisions of
Professionals Code, and nyLicenoe�inhd|�nmand o#oo�
uom�e # �,Lic. Class Exp.,Date
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'Date Signature'
OWNER -BUILDER DECLARATION,
I hereby affirm under penalty o - f p'erjury that I am exempt from the Cont6actor's
L.icense Law for the following reason:
( ) 1, as owner of ' the,property, or my employees with wages.as their sole
compensation, will do the 'work, and the structure is not- intended & offerbd for
sale (Sec. 7044, Business & Professionals Code).
1, as owner,of the property, am exclusively contracting yvith lic�nsed
a con I 'ruct the project (Sec. 7044, Business & Professionals
ors to
;dle
WORKER'S COMPENSATION DECLARATION
|,homuy affirm' of perjury of the following uoo
()|xmeand will maintain ocertificate mconsent maelf-|noumfor workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
pohonnonoo'cxthe wnm�,wmohthis ponnniaissued.
'
~' ( ) | have and will maintain workers' compensation inoumnoo, as required by
aoohon n7on'of the Labor Code, for the performance ofthe work for which. this
permit is issued. myworkers' compensation insurance carrier & policy no. one:
CanierPonoyNo� .
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����o ��nmboo�p�o �mop�m�v��o �hx�o�om��
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|�cartifyin the performance of the work for which this permit is
I shall not- employ any person in any manrier so as to become subject to the
workers' compensation law ' s of California, and agree that if I should become
subject to th . e workers' compensation provisions of S 00 of the Labor
G ode, I shall forthwith comply with those 1�rovisions.
Warning: Failure to secure Workers' Compensati.6hW cove rage is unlawful and
�.shall subject anemployer to criminal penaltiesup-to $1nn.nnn.m
addition mthe cost cdcompensation, damages aoprovided for- inSection 3706
mthe Labor Code, interest and attorney's fees.
IMPORTANT Application iohereby made mthe Director cxBuilding and Safe t�
for a permit subject to the conditions and ,omn000no set forth on mw
application. � ��t
1.saohpomonupon whose behalf this application ismade & each person ox�
whose request and for whose benefit work iopo�jonneclunder o, pursuant.to
any permit issued ooaresult orthis appnooxonagrees to, mshall, 'indemnify
& hold harmless the City o,LaQuinta. its officers, agont6anU omp|nyeoo'
2. Any permit issued as a naou|t v/,thio application becomes null and void if
wv,x is not commenced ~nxm 180 duvo from umo of issuance of such
pannit, or cessation ofwork for 18odays will subject permit mU i fV 9.
|oem�mot|have madthis oppnoahonand o��moxmo'aUovoinh�maVonio
correct. | agree too6mp|ywith all City, and State laws relating tothe bui| g
construction, and hereby authorize representatives
ofthioC|�mmo
. o, n
the above-mentioned property / i
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Signature �xwno�xgo latef" Cl
L
BUILDING PERMIT 5 40 7
.D�TE VALUATION IT TRZ7
JOB SITE APN
ADDRESS '$1465 AVENIDA, VELASCO
CONTRACTOR / DESIGNER /ENGINEER .
'
M". r-JUBUILDER���
L A CK CA, 92253
ANTA
CUR
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1 �/���
USE
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POKC111TA710
` 440.00 Sr.
ENVIAtVf ED COST OF C. 0INSTRUCTION'
1P.MKIT 0,'_E' SUMMARY
MAIN CAKX. np 1.01 -OW -439-318 $52.6
M -M, 101~000-418'080 $hlM
r, PONQDJX''>�2Q� 101-X%� S.50
^ . ` . . ...` '
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AND PLAN CHECK
.lJSS PRE -PAW |
�l��� �0���0����'
�� = "~x.°�^�.~�="^" �
~ ~ ~
,1011DATE By DATE FINALED
INSPECTOR
'N..S52.00
$134.24
$134.24
INSPECTION RECORD.;..__
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0.0o 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 - IM. 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 I I
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:
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)
C
t
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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 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 woik, 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-Staie 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 Stare
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. ' I R
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
i
PROPERTY ADDRESS
• PERMIT NUMBER(s)
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