9809-130 (BLDG)LICENSED CONTRACTOR DECLARATION
' I hereby affirm under penalty of perjury that I am licensed under provisions of
~Cha:a, 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
01.8
Date Signature of Contractor
OWNER -BUILDER DECLARATION
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 wages as their sole
ddImpensation, will do the work, and the structure is riot 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).,, I F
( ) Ilm exempt under Section , B&P.C./for this reason
:pate !( r .F Signature of Owner r
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).
() 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those, provisions -,
Applicant
f
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal p nalties 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 a bove-mentioned property for inspection. purposes.
..Signature (Owner/Agent) '1 R y / r Date
BUILDING PERMIT PERM'S °°NTR°`#
DATE .� VALUATION LOT TRACT
�,� 8244
JOB
ADDRET Sr 77-670 MLE S NALOA
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JAMES. C't1LTAKENBUSIJ
OWN "E:R!PUILDE.R
77-760 CALLS S[NALOA
LA QW10'A C.A. 92253
USE OF PERMITT�
� {
GF,!Q,.R1'N.L, .CJUI!.I�11�4Y
125 L,F. IWOO;1.FRAME S' f UC -CO i"INUE.T' Y fUGH WALL PA1NT"rl7 TO
MA'T'C141f )USE.
511T. etOO13 PENCE, 125.00 LI:
t'. ED COST Or! CiJI�tSl—RUC:"BION �
957.5€4
gp �`,,��,�{{ jj gg yy'��;t �qyp�g;� ,,�� [UtiES•TYINI
PER -MIT
439.318 `'lti,25
PLA4C;HJ-,'C-'d;,FEE 401-OW439-318
;SZ. IVIRS1'AId C 0NS't'FtUC`l103%i.AXD PLAN CHECK
$41.25
3.:LSS ['RC-PA.WEES
$0.00
SYD'a'A . P)MMIT 1+'E1NS 0AJi`,.N0%i/
RECEIPT , fe ;
DATE r / tt
BY' {
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings Q
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
CG l7 .f�C
G
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)
OWNER/BUILDER INFORMATION
r
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 hs orrher name.
Contractors are required by law to be licensed and bond:d 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 rariuus 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 thany our 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 2nd 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 ou= these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations un&r.Federal Law, contact the Internal Revenue Service (and, if ;
you wish, the U.S. Small Business Adminstration). For rnore 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.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner _s 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 v=rification 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 ,
OWNER'S SIGNATURE/ DATE
77670 ' ` Ca (� S i-jo1
PROPERTY ADDRESS
PERMIT NUMBER(s)
SENT BY:Pharmavite 9-28-98 ; 1'07PM DISTRIBUTION CENTER- 760 777 7O11;it 1
MES C. QUAKEN' USH
15943 Grey am Street
No. Hil 4
- � CA
09/28/98 91343
Mr.. reg Butler,
City of LaQuinta, w
La C Uinta; CA
FAX 760 777 7011 i.
Dear Mr. Butter:
Re: 77670 Calle Slnota,
This La Qclinta
ill confirm• your request to Mr. Larry Coia.
This i to advise`#hat Mr. La .
M. be alf necessary.�Y Coa is authorized to sign necessa
above address_, to complst® application and work on m
ry documents; n
My home at the
If :you have any questionsplease Ilsel
during business flours ofree to call
r at home, me at 800 423 2406, X 7200, !'
Yours truly,
mes Cr. Quakenbush
CC. Mr. L. Coia
FAX 818
894 3057. EMall: Qua •.r .
k1�Pharmav4e.com Phone 618 87
94 g
7