0306-210 (PLBG)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm.under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W, Professionals Code, and my License is in full force and effect.
o �C) License # Lic. Class Exp. Date
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oZ r,- Date Signature of Contractor
(O 0- r
J U C:) OWNER -BUILDER DECLARATION
W UJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ (v\) 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).
Q,I'am exempt under Section B&P.C. for this reasonLID �^
C\JN /Date Signature of Owner I
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C\1 `
d Q WORKER'S COMPENSATION DECLARATION
C:) I hereby affirm under penalty of perjury one of the following declarations:
U-) Hcc
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
M Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
tl rn f— permit is issued. My workers' compensation insurance carrier & policy no. are:
Nt Z Cartier Policy No.
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(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,
l,i+shall not employ any person in any manner so as to become subject to the
�vorkers' 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. c
Date: Applicant—
Warning:
pplicant 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
�1 any permit issued as a result of this applicaton agrees to, & shall, indemnify
map & 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. i
l,.,Signature (Owner/Agent) Date
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BUILDING PERMITRMIT#
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DATE VALUATION LOT TRACT
JOB S"t
APN
ADDRESS -ME, AVEMA V &JO
_ ry
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JOWUA MARP
0 W*(,R BW( i'
54.835 .AVIMIDA VALLWO
f`,A 92253
USE OF PERMIT
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38PTIC .A.B.6:NDCiK1M04TtSF. WE1?, L:'R.7NMEA T 4
TV ALUATIOW 100.W Li
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Pig P•? B1140 W, $XWER .101-000.419.000 MIA ,
tai � ti r 1 T .$tXYr11T10X AND PLWI 03M ox
D DITE
� , PXRMTFFX8 NOW
JUN 13 2003
CITY OF LA GUINTA
FINANCE DEPT' - .
14,
RECEIPT
DATE! / n /
BY.��/. .•--^^"""
T
INSPECTOR"
h
0
INSPECTION RECORD
OPERATION
DATE
I 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
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
c
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
t 7
Final
COMMENTS:
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)
M
TOTAL $
Water Service
Cashier y.
CVWD-438 (11189)
Remarks:
COACHELLA VALLEY WATER DISTRICT
95997
CASH RECEIPT DETAIL
Q'Copy to:
Cash
Check
Money
Order
Received From.--.L--Date:
Address:
Account No. �6
Lot(s)
Tract
tf
Service Address-�
41i;
G.A. Code
0 Meter(s)
$
0 Service(s)
0 Backflow(s)
0 HouseLaterai(s)
0 Detector Check(s)
0 Meter Surcharge
Sanitation Capacity Charge
11 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account -Name
1
0 Inspection Fee -Tract -
I
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
M
TOTAL $
Water Service
Cashier y.
CVWD-438 (11189)
Remarks:
Q'Copy to:
Cash
Check
Money
Order
M
TOTAL $
Water Service
Cashier y.
CVWD-438 (11189)
' S
VALLEY WIDE PUMPING' -SERVICE
`Your Waste Is Our Problem"
JOB INVOICE
8577
L V V J. JUI II laU Vvcly JUILG 1,j -
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CUSTOMER'S ORDER N0.
DATE ORDERED
PALM SPRINGS, CA 92262
Gallons
ORDER TAKEN BY
PROMISED ❑A.M.'
(76 0) 322-2400 (760)347-3545
Pumping Fee per 1000 gal.
❑ P.M.
BI
PHONE
Dumping Fee per 1000 gal.
ADDRE S
EC
CITY
'ELPER
JOEI NAWEAN15 LOCATION
❑ DAY WORK
Y
DES 1 TION OF WORK
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❑ CONTRACT
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QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
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A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR
WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR
AMOUNT
TOTAL
MATERIALS
MECHANICS Q
HELPERS Q
TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED
1.2( lD
TOTALlr,�'
To Reorder Call NEBS CUST&M-printing service TOLL FREE 1-800.888-6327 NEBS, Inc., Peterborough, NH 03458. Ret. No: G 710703566
NOTICE TO OWNED
Under the California Mechanics Lien Law any contractor, subcontractor, taborer, supplier
or other person who helps to Improve your property, but is not paid for his/her work or
supplies, has a right to enforce a claim against your property. This means that after a couit
hearing, your property could be sold by a court officer and the proceeds of the sale used to
satisfy the indebtedness. This can happen even if you have paid your contractor In full if the
subcontractors, laborers or suppliers remain unpaid.
To preserve their --right to file a claim or lien against your property, certain claimants such
as subcontractors or material suppliers are required to provide you with a document entitled
"Preliminary, Notico." Original (or prime) contractors and laborers for wages do riot have to
provide this notice. A Preliminary Notice is not a lien against your property, its purpose Is to
notify you of persons who may have a right to file a lien against your property if they are not
paid. Generally, the maximum time allowed for filing a claim or lien against your property is
ninety (90) Days after completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS:
1) Require that payments be made directly to subcontractors and material suppliers through
a joint control. Any joint control agreement should include the addendum approved by the
Registrar of Contractors.
2) issue joint checks for payment, made out to both your contractor and subcontractors or
material suppliers involved In the project. This will help to insure that all persons due payment
-
,*are actually paid.
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3) After UPON making payment -on any completed phase of the project, and before making
any further payments, require your contractor to,provide you with unconditional lien releases
signed by each material supplier, subcontractor and laborer Involved in that portion of the
work for which payment was made. On projects Involving improvements to a single family
residence or a duplex owned by individuals, the persons signing these releases lose the right
to file a claim against your property. In other types of construction this protection may still be
Important, but may not be as complete. TO PROTECT YOURSELF UNDER THIS OPTION YOU
MUST BE CERTAIN THAT ALL MATERIAL SUPPLIERS. SUBCONTRACTORS OR LABORERS
HAVE SIGNED.
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
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 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,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:
r
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. 1
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,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760)777-7012
FAX:, (760). 777-7011 /
'S SIGNATURE IRATE
PROPERTY ADDRESS
PERMIT NUMBER(s)