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9801-019 (BLCK)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 Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date J 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: 0Y) 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). (�) I am exempt under Section B&P.C. for this reason Date ij` Signature of Owner J 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 i' Policy No. (This section need not be completed if the permit valuation is for $100.00 or less). (V I certify that in the performance of the work for which this permit is issued, I stiall 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. ,Date: ,� ,, Applicant_t 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 pursuarif+to any permit issued as a result of this applicaton agrees to, & shall, iridemnify & 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. /gnature (Owner/Agent) "! •�-In--•_•_� Date PE - CONTROL# BUILDING PERMIT DATE 'II (j19pd 'VALUATION• as _S � LOT TRACT. (� 676 JOB SITE ADDRESS 44•-215 SWIi !,T BUSH. LANG APN (��j�i a•®�.2•y OWNER CONTRACTOR /DESIGNER /ENGINEER DOUG[AS » t JAV4TA ADAMS 0,bNMR, OUT 1,T)IIR , 442 15 SV i,. -..r jiusil LN LA QUINTA CA 92253 USE OF PERMIT BUL.IANG l % �..l+.y b' C• A.Cti3i�v L�'f1l..�.., r.%l'il� ),� yT/�fJl�«�1� �1�1T1•k `�'ir1� 3` �R'Itf�UCi��'L' )K.ON CA'I'FS Or, W1-ir3Hi QJR AQi FH_"ME*NT A'' TAC:I16D) COST OF COINSTRUVICTION CONSTRUCWON FM 101-000-418-000 S45, 1) t Sull-`x'Cz'IA f . C;( -)NS `�idi:"3' ON Al PLAN c::i'IEC USS PRE -PAID FEES 50.00 �3 1998 . ' ' T IAL P:Eytt1Iff s• ::.4 0I::] fit:: (YW- Liko RECEIPT DATE,By L `^ DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR BUILDING APPROVALS Set Backs Forms & Footings Slab Grade Steel Roof Deck O.K to Wrap Framing Insulation Fireplace P.L. Fireplace T.O. Party Wall Insulation Party Wall Firewall Exterior Lath Drvwall - Int. Lath OPERATION DATE INSPECTOR MECHANICAL APPROVALS Underground Ducts Ducts Return Air Combustion Air Exhaust Fans F.A.U. Compressor 1 Vents Grills f Fans & Controls Condensate Lines Gas Test v i Appliances COMMENTS: Final ELECTRICAL APPROVALS Temp. Power Pole Underaround Conduit Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Penn) Final BLOCKWALL APPROVALS POOLS - SPAS : Steel Set Backs Electric Bond Footings — Main Drain Bond Beam 9— 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 i Pool Cover Sewer Connection Encapsulation Gas Test v i Appliances COMMENTS: Final ELECTRICAL APPROVALS Temp. Power Pole Underaround Conduit Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Penn) i CV 0F fF1�9wSw 78-495yCALLE TAMPICO — LA•QUINTA, CALIFORNIA 92253 r v - TELEPHONE (760) 777-7012.• FAX (760),777-7011 a r + OWNER BUILDER INFORMATIONti Dear Property}Owner.: •• , + �' AnaPPlicado•n for, a building P;ermit has been submitted in your name listing Yourself as the.builder of the ro ert Y• improvements specified. + • p 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 orher 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'Couniy: They'4are also required _by law to put their license number on all permits for which they +' apply. �N 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 of subcontractors, then you may be 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, fedeial 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 spe6fic-information about your obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. _ , • ` + ' If the stiucture 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 io be contiactor5 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 s . personally. Information about licensed contractors may be obtained by contacting the,Contractors' State LicenseBoard 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: „ 1 ..Verytruly, yours, �_ - .• ,_= . .• - + - - CITY OF LA QUINTA s DEPT: OF BUILDING AND SAFETY ' 78495 Calle Tampico - La Quinta, CA 92253 (7 0) 777-7012 F ' (760) 777-7011: OWNER' SIGNATURE/DATE I TAW PROPERTY.ADDRESS - + PERMIT NUMBER(s) } {