0203-408 (RPL)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
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).
( ) I am exempt under Section B&P.C: for this, reason
Date � .-Wt�r'r_. Signature of Ownerr�
T 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.
Date: Applicant
Warning: Failwe 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. 7
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 fo
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 isnot commenced within 180 days from date of issuance of such
permit, or cessation of; work for 180 days will subject permit to cancellation.
1�
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.
q
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/A ent)i nature (OwneDate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 02,03-408 TRACT
JOB SITE
APN
ADDRESS 79 '8KiAga,ECc,01, r V
.-
OWNER //
�1
CONTRACTOR / DESIGNER / EN (NEER
DAVAID L Mi7r
OVOM - L3iJiWER
,79-145 KA -19 COURT
CA 97, 53
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'4.: Lj,R
USE OF PERMIT ,-
POM ANDIM, EPA
POOsd"dP.A AL.#'.PJ4.VBAkmJ*EH8 SHALL 09 IN PLACE K'f2TOR TO
PUPI Ai11 R INISNECTIO , 20 W? IP 0ARD014 WA1,14 CiTy 14TANDARO,
-71 LF OF "IV 0,,MtM WALi. 42 LF 0? 233° Q.A.RDZN VftL1l.n
Pl�pp��t1,Y.x_A�Y�)D)JOR.SPA 3berG�€1IN 1XI `
6 fl. kY.w'Wie I /lf.f1Q Sxl�
.
PLAN CHECK F0, 101.000439«318 $1140,40
CrONS`l`.R11' ' 11(yu Me 101_0004MOGO $216.00
MECHANICAL F.99 -- POOL. 101,-000.421 ^000 $24,00
ELEC:'1'Ff;1.tIAL.F '- POOL 101-000-4 20-000 v xo
P1MAMO-FES -POOL. O" 101 -000-419-;000'
s.
lk
STYR TCAAL:CC��L'�.t�'�.I�1f�i�'.P�l�x, N CHWIC
452,40
L.AL 11EMTIMES DW: NOW
$452A0
`. 4,
�CITYOFIt A�QUINTA .
RECEIPT
DATE BY
/-/• lfj- �r�1
DLE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings —/2— y
Main Drain
Bond Beam
Approval to Cover
Equipment Location
t
Underground Electric
Underground Pibg. Test
< 2
.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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
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)
' INTERINSURANCE EXCHANGE of the Automobile Club
PROPERTY INSURANCE RENEWAL DECLARATIONS
i AUTO CLUB MEMBERS' PREFERRED HOMEOWNERS POLICY—FORM 3
,EASE READ: These declarations constitute our offer to renew this insurance for the policy period shown below. Renewal is
ontingent upon your payment of at least the Minimum Due before or on the Due Date shown in the enclosed Insurance Billing.
,,Failure to pay at least the Minimum Due before or on the Due Date shall mean that you rejected this renewal offer. All coverage
''afforded by this policy will then terminate at 12:01 a.m., Pacific Standard Time, on the Effective Date shown in these declarations
under "Policy Period." These declarations, together with the contract and the endorsements in effect, complete your policy.
ITEM 1. YOUR NAME AND ADDRESS PROCESS DATE HO POLICY NUMBER
4-30-01
H26 PH 3619600
PRICE, DAVID L AND TAMMIE SUE
79145 KAYE CT
LA QUINTA CA 92253-7209
POLICY PERIOD (PACIFIC STANDARD TIME)
EFFECTIVE DATE 6-28-01 12:01 A.M.
EXPIRATION DATE 6-28-02 12:01 A.M.
ITEM 2. LOCATION OF RESIDENCE PREMISES (IF OTHER THAN ABOVE)
ITEM 3. COVERAGES AND LIMITS OF LIABILITY (YOUR POLICY AFFORDS ONLY THE COVERAGES FOR WHICH A LIMIT IS SHOWN OR DESCRIBED BELOW. COVERAGE FOR RESIDENCE
EMPLOYEES IS AFFORDED ONLY FOR THE NUMBER OF EMPLOYEES SHOWN BELOW.)
PART I—PROPERTY COVERAGES
A B
OTHER
DWELLING STRUCTURES
$196,000 $19,600
GUARANTEED REPLACEMENT
COST INCLUDED
PART I1—LIABILITY COVERAGES
DEDUCTIBLE
IN ACCORDANCE WITH OUR INFLATION ADJUSTMENT INDEX, PART_ I LIMITS
HAVE BEEN ADJUSTED BY 3.90 %
ITEM 4. ENDORSEMENTS IN rFFFrT
PERSONAL INJURY
AGGREGATE
$300,000
PART IV—WORKERS' COMPENSATION
AND EMPLOYERS' LIABILITY COVERAGES
E
OTHER COVERAGES
G
C
S. BUILDING
1. LOSS OF
D
4SCHEDULED
CODE UPGRADE
USE
PERSONAL LIABILITY
PERSONAL
10% OF THE
20% OF THE
BODILY INJURY AND
PROPERTY
AMOUNT OF
AMOUNT OF
PROPERTY DAMAGE
$147,000
COVERAGE A
COVERAGE A
EACH OCCURRENCE
DEDUCTIBLE
IN ACCORDANCE WITH OUR INFLATION ADJUSTMENT INDEX, PART_ I LIMITS
HAVE BEEN ADJUSTED BY 3.90 %
ITEM 4. ENDORSEMENTS IN rFFFrT
PERSONAL INJURY
AGGREGATE
$300,000
PART IV—WORKERS' COMPENSATION
AND EMPLOYERS' LIABILITY COVERAGES
E
F
G
MEDICAL
WORKERS'
EMPLOYERS'
PAYMENTS TO
COMPENSATION
LIABILITY
OTHERS
PER CONDITIONS
EACH PERSON
STATUTORY
PART IV,
PROVISION 3.
HO -216
NUMBER OF RESIDENCE EMPLOYEES
$1, 000
Ir
OUTSERVANT(S)—
O:INSERVANT(S) - 0
NUMBER
TITLE
PREMIUM
HO -184
INFLATION
ADJUSTMENT ENDORSEMENT
HO -216
ALARM OR
FIRE PROTECTION SYSTEM
HO -290
PERSONAL
PROPERTY REPLACEMENT COST
$ 42
4388FU
LENDER'S
LOSS PAYABLE ENDORSEMENT
THIS POLICY DOES NOT PROVIDE COVERAGE
AGAINST THE PERIL OF EARTHQUAKE
ITEM 5.
MULTI POLICY SENIOR
NE:W HOME
FIRE -RESISTIVE ROOF FIRE ALARM
I
BURGLAR ALARM
DEADBOLT
PREMIUM DISCOUNTS
YES NO
)YES
YES YES
I NO
YES
ITEM S.
BASIC
LESS
ADDITIONAL COVERAGES
NET TOTAL
PREMIUMS
COVERAGES
DISCOUNTS
INCREASED
INCREASED
RESIDENCE
ENDORSE-
CIGA
ASSESSMENT
PREMIUM
PERSONAL LIABILITY
MEDICAL PAYMENTS
EMPLOYEES
MENTS
$698
$279
$25
$42
$486
••• --�� �•- •.••• �.w�c... �WVv nMUCa—IJ rATNOLt AJ INItMtJI MAY APPEAR TO YOU AND
MORTGAGEE i LOAN 0 WSCO12979C
GUILD MORTGAGE CO
AND/OR ITS SUCCESSORS OR ASSIGNS
P 0 BOX 85304
SAN DIEGO CA 92186
II
HMR0040A FOR OUESTIONS OR CHANGES CALL TOLL. FREE 1-800-924-6141
-
CITY OF LA QUINTA SUB-CONTfACT.QRIST
JOB ADDRESS �CH(45 &�V/c 0* PERMIT NUMBER OWNER r J-f!��_ BUILDER V`l � -
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous dace. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade / Classification Contractor
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification .
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)(xxxx)
License Number
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)—
� C
34/OZ
2 O
CONCRETE (C -8) -
FRAMING (C-5) '
STRUCT. STEEL (C-51)
MASONRY C-29 - 4
_
79
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PLUMBING IC 36) �5.'
a
_
LATH, PLASTER (C-35)
6
3
,
n
o D
Cd "Z Q�
3l
DRYWALL (C-9) _ - .
a 9
l
HVAC (C-20)
ELECTRICAL (C-10) C
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
C-1 AZIRIG
INSULATION (C-2)
SEWAGE DISP. (C-42)
PAINTING (C-33)
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING (C-13)
LANDSCAPING (C-27)
POOL (C-53) /�'
C
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W-- "
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t
4,4
78-495 CALLE TAMPICO
Q"
LA QUINTA, CALIFORNIA 92253
TELEPHONE (760) 777-7012 FAX (760) 777-7011
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.
II
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 lawto put their license number on all permits for which they
apply. il
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 f4or your benefit andprotection:
If you employ or otherwise engage of persons other than our immediate family, and the work (including materials
Y P YY P � Y Y• ( g
and other costs) is $200.00 or more for the entire lroject, and such persons are not licensed as contractors or
subcontractors, then you may be an :Imployer.
If you are an employer, you must register with the Stat 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 t1ut these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information aboutlyour 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 Stare
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale,J 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. �1
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building
permit, erroneously implying that i:he 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 grill not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA it
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012 {
(760) 7
7-7011
-d 5/,2�2
OWNER'S SIGNATURE/DATE J�
19-/qs (Kaci CO.
PROPERTY ADDRESS
oao3 - X08
I
PERMIT NUMBER(s)
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�NIT.
CITY OF LA QUINTA
Ccde V e' BUILDING & SAFETY DEPT.. 1
I-c� Qu�'nla Ccs. �gt�i�i.
g2zS3
760-ce
FOR CONSTRUCTION
DATE �-10-01 BY e -4f
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