9910-104 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chanter 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
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
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).
() II am exempt under Section B&P.C: for this reason
Date It's - Of / O• Signature of Owner
WORKER'S COMPENSATIONDECLARATION
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:
Cartier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( )y 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.6 the workers' compensation provisions of Section 3700 of the Labor
Code I shall forthwith comply with those provisions.'
,Date: IL -Applicant—
Warning:
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
thbove mentioned property for inspection purposes.
Signature (Owner/Agent)A se .� Date ��� `� ! 1
BUILDING PERMIT PERMIT#-
DATE / VALUATION T4.f)ft� LOT' TRACT
ADDRESSJOB SITE I 7.9- 2A TO R,fO1N JA
APN w
OWNER
CONTRACTOR / DESIGNER / ENGINEER
//-�
J.C. iw1F. 6ji4i.
�1� 1i'.a � 1 Fri/.i i Y:ti
79-: 0 TORONIA
1.AQ'tlMIA CA 4422,531
USE OF PERMIT
PATIO
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'VAL u:, W1-U�"3 1.itt6
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;Y 11i!'s1 t) li iJt`PON Ffll -14f140 1,01410 -2,11 -WO
RECEIPT
DATE
BY ^''
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE I
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 , Ga
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
Furfures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
END TO
Company name • S From
Attention e a e .
Ullice location'
office ca wn
ax numb
Pgane number
•;� Urgent Reply ASAP El
Please comment E] Please review, For your information
. Total pages, Including cover. ( +
�'.
COMMENTS
Fi�J
Professional, Community Management / Desert Resort Management '
Post_Office Boz 4772 .'PaltnDeseit, CA 92261-4`-72
73=550 Alessandro, Suite 5 Palm Desert, California *'.',(760) 346-116.1: • FAX (760) 346-9918
OF 9wSw - 78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253 ,
TELEPHONE (760) 777-7012 FAX (760) 777-7011
w 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
' permic. 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 thanyourself, 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: '
J t J
a
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and othercosts) 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 of through their own employees, without awlicensed 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 Contractor's' 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 unid the verification is returned.
Very' truly yours, `h
CITY.OF LA QUINTA .� - - , • - -
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico ;
La Quinta, CA 92253 r 4
(760)/377-7012 s
F 760 y77- 01 -
?'11NE SI RE/DATE
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PROPERTY ADDRESS `; r
'PERMIT NUMBE (s)
r,
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i r --p -.-770
f OF LA QUINTA
y BUILDING & SAFETY DEPT,
'APPROVED
j FOR CONSTRUCTlo _
BY
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1 ••(� .y Y .2 •� INSPECTION FEE or, 130 '
• _� �_ i F 'BE CHARGED 9 THE APPROVED'
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BUILDING & SAFETY DEPT
AP " PROVED
FOR CONSTRUCTION
DATE BY
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BUILDING & SAFETY DEPT
AP " PROVED
FOR CONSTRUCTION
DATE BY
STS'-
42
42" Stainless Steel Outdoor Fireplace „
S Produ 'Suggested Retail „
•42" .Outdoor Fireplace $1;599
• Stainless Steel Construction Protects it From Outdoor Elements e
• Drain Channels to Minimize the Effects of the Weather r ;
• Clean Face Design Allows Finishing Materials to be Brought Up Right, to the Opening for
An Authentic Masonry Look
• 42" Firebox Opening `
• Realistic Brick Refractory
• .Standard Grate CITY OF LA Q U I NTA
BUILDING & SAFETY DEPT.
• Optional Bi-Fold Doors ® `'
• Gas Access on Both Sides for Convenient Installation of Gas Logs A I�®p R O V E D .
• ° 15-Year Limited Warranty
FOR,CONSTRU.CTION
:i DATE '' BY
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