9912-216 (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 DATE "
Pi�fessionals Code, and my License is in'full force and effect.
License # ' Lic. Class � Exp. Date
JOB SITE
ADDRESS
Date Signature of Contractor k L4 ,OWNER
OWNER -BUILDER DECLARATION.T� i�,F`�t;
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 ages.as:their so e+ `
compensation, will do the work, and the structure is not int nded oroffered f 'r° y
sale Sec. 7044, Business & Professionals Code).
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( ) ` USE OF PE
. ( ) I, as owner of the property, am exclusively,00ntracting with lien d
contractors to construct the project (Sec. ({7044; Business & Professio% als •„ t
` BUILDING PERMIT PERMIT'��E� }
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99MALUATION ;'S40ollf)tj LOT ;_ TRACT'(
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' - CONTRACTOR / DESIGNER / ENGINEER
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,frA/'�::ft('f�f " • (`� [y�.�(pjpp {�/jam {'�
3.AVEXi� A W,LASCO
r UINTA. CA 92253
s a ( j - C..RiS
O I am exempt under Section B&P:C. forithis reason ;J
at TIT I C
Date �� ..l •,:.4Gi Signature of Owner-N,-�s••-_ . _
WORKER'S COMPENSATION 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).
() 1 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 becomeJsubject to the
workers' compensation laws of California, and agree that/if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with"'those provisions( t
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. - -e.
1'., Each person upon whose behalf this application is made & each persori 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 ie 7-1
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)ON 9,G*T-R c"'`O`ivNFCT
v ALUA 1
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ESTINUTE,D COSI OF CONS'9;Ri:7C`. ON
PERMIT FEE SUNiNURY, -
PuJMBiNC-i %-bi 101-00'0-419-000 SI -V.00
Ci fi�'IT71_Ai, Ci3i4f�1Ti�(T(�"1'iCW ANn N AIN C 4F -CV
t.Err PPE-P,AJ.b FEES
RECEIPT DATE
TOTAL PERMIT YCES Ville NOW
DATE FINALED ]INSPECTOR
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400.00
1 .
$30,00
$0.00
$30.00
INSPECTION RECORD
k 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
O.K. to Wrap
F.A.U.
Framing
Insulation
Compressor
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
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
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:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
Address: �7r , LA S C
Account No. Lot(s)
F1
Service Address
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Me Surcharge
'Sanitation Capacity Charge f N
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
•❑ Customer Deposit
❑ Other
Remarks:
Y to: /7
Cash
Check 4'
Money
Order y ''
10
N. • .76857
)ate: 7.7- 9
g -12-V"CA.
Tract
G.A. Code
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TOTAL $ _17 L—, � a�
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Water Service
�i Cashier
CVWD-438(11/89)
OWNER / BUILDER. INFORMATION
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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 variuus 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 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 inyour
community or at 1020 N. Street, Sacramento, California 95814.
_Please complete -and -return the. enclosed _owner -builder verification form so .that we -can corifi_rm -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
(760)777- 0 1
OWNER'S SIGNATURE/DATE
C
PROPERTY ADDRESS
PERMIT NUMBER(s)
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