9605-040 (PAT)LICENSED CONTRACTOR DECLARATION,,',,".
I hereby affirm that I am licensed under provisions of Chapter 9'(66mmencing 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 Signatureof Contractor
OWNER, -BUILDER DECLARATION
I hereby affirm 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).
() J I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044; Business & jrofessionals Code).
( J� I a _ x mp u der Section B&PjC. four �this 'reason
DateSignatureof7/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�ection need not be completed if the permit valuation is for $100.00 or less).
( 4 '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 become subject to the
workers' compensation laws of California, and agree that if I shout /become
subject to the workers' compensation !provisiions of S lion 3700'of a Labor
Code, I s, .hal jo° with comp" those�,Yr,/,.X.,
visions`. A"T ./Date: / '` Appli6ant - /� l� .✓ a%
11 .. ,-i I X
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 Stade laws relating to the building
construction, and hereby authorize rep . -en ta Dies of this City to enter upon the
above-mentioned property for in ecti ri'pur
Signature ( (/Agent) . ° t / .�7y1'/ t / Date
V
ALC#§��
-BU:ILDING'PERMIT "-4i'i
PERMIT#
DATE
VALUATION
LOT
TRACT
J08 SITE ADDRESS797.10 STARFLOWER
APN 6"251-002;,4.
OWNER
CONTRACTOR
101 -TIN r RA,Gi.MITE (.ARTC"TCYT'
r
CWNE-lb"BUILDER -
'79710 STAk hLOWER
I
LA. QUINTA C;A. 92253-
2253W-3163.3
W -1163.3
DESIGNERIENGINEER E.t4 fF
USE OF PERMIT
A Ci
FEE DESCRIPTION
FEES
YORCI-ift'AT IO 168.00 SF
li:. UNJWED COST OFCONSTRUCTION
U44.40
nk-mi ii , milf. SuIbIlmAHY
PLAN C URCK FEE 101-000439-318
C"ONSTRU'C71ON.ME 101.000-418-01)4
ST014 i N40TION FEE •- Hr- SID 101-0,00-241-300
.
Cfl
O
aC.
Q
SUB -TOTAL CONS- 3WCTION AND PLAN CHECK
S89.60
,LESS PRE -NUN FEES
$0.030
TOTA4',PERMIT FEMI1DUE NOW
$#9.60
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings az
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 ot
BLOCKWALL P ROVALS
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
Appliance's
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
S
Final
Utility N `ice (Perm)
COMMENTS:
• OWNER/ BUILDER: INFORMATION
year rroperty 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'someorie 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. Theyare 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 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 State and Federal Government as an employer andyouare subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs andunemployment compensation contributions.
There may be financial risks for you if you do not cairy oucahese 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 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,
yV11
CITY OF LA QUINTA �` y
DEPT. OF BUILDING AND SAFETY =
78-105 Calle Estado
La Quinta,. CA 92253
(619) 564-2 6 .
FAX: (619 6
O R'S NATURE/DATE
POP RTY ADDRESS
PERMIT NUMBER(s) -