The URL can be used to link to this page

9604-139 (DEMO)LICENSED CONTRACTOR DECLARATION 'A hereby affirm under penalty of perjury that I am licensed under provisions of ,_'li�hapter 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 , a3o581I f 1' , ate 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 Signature of Owner WORKER'S COMPENSATION DECLARATION . I 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 /ection 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 all 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; l' h'all fo bwith comply with t se provision p e: ! Applicant .� Warning: Failure to secure Wo ers' Compensation coverage is unlawful Ltd . 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 the above -mentioned property fgy inspectiUD purpose§. „` _ Signature (Owner/Rent ��.� •' Date BUILDING PERMIT PERMITWWI39 - CONTROL# 3 212 DATE 4126196 VALUATION S:Ja(,tw LOT TRACTJOB SITE ADDRESS 13 AS 78.730 LA 3A APN OWNER CONTRACTOR / DESIGNER / ENGINEER OARY I, & SIIARJN'.0Ci 21 I3AWIN)NT C ON.SURUC"TSOT"! 78730 AMID LA JIMIUTA 74.773 h1N,RWE DR LA QUINl'A CA 922: RAl: M MSEWr CA. 92260 ftifa}5( 2 lQ OR 83k"581 i USE OF PERMIT T?ENKAJ 110N ;DEMO ['Iltti rJAi'vi:ADE ONLY vru.tlr�: ixJAv �,tta .irtr ,L. ESi":I'.E'NM`,i'ED C;`C1S`r OF C<'€ NSTR4)C:.dl`tON .S,I!(10.i3U 10VOLITION f^"C0: ltiirl)OU # (10() ' , $45.00 " ; . C'fryi�iS Tt::rC T�C�TN A to PT.11t C tI CIC, $45.00 f USS Pik-PAJO rEe::5 $0..00 APR 2.6 1996 MAL PI,aRMU F E.N EAU NOW �z erg By -- RECEIPT DATE BY DATE FINALED INSPECTOR t t INSPECTION RECORD t 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 WraD F.A.U. Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall _ int I ath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam 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 I Equipment Enclosure Shower Pans O.K for Finish Plaster `Sewer Lateral Pool Cover Sewer Connection I Fnrami latinn Final • COMMENTS: Final Utility Notice (Gas) / ELECTRICAL APPROVALS Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors TemD. Use of Power Final Utility Notice 4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 Riverside, CA 92501 Banning, CA 92220 Ph: 787-6146 Ph: 849.7312 rrnmn nrruonrrun County of, Riverside Department of Building and Safety 880 N. State Street 227 North "0" Street Hemet. CA 92343 '+ Perris. CA 92370 Ph: 658.4464 Ph: 657-3898 46.209 Oasis St. Rm. 310 160 N. Broadway Indio, CA 92201 Blythe. CA 92225 Ph: 342-8271 Ph: 922.2670 This permit becomes void if work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandoned for a period of 180 days. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. Number Dale Contractor OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter• improve• demolish• or repair any structure, prior to its issuance,'also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): M V I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the sTruilure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himsell or through his own employees, provided that such improvements are not intended or offered for sale. If. however• the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.). - . Psi 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. ness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law.). J". 1. - ❑ I am exempt under Sec. •""=�^"� . B. 8 P.C. (Attach Certificate) ...�s�, Date► �� r Owner. —✓ s WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have'a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance.lor a certified copy thereof (Sec. 3800, Lab. Q. Policy No. I Company Certified copy is hereby furnished. Certified copy is filed with'the County Building Inspection Department or County Applicant Department. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the permit is for one hundred (8100) 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. Date Applicant NOTICE TO APPLICANT: If. alter making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: , Of hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2. Sec 341. Title B. C.A.C.) / As owner -builder. I will not employ anyone to do work which would require a permit from the Division of Industrial a ety, as noted above, unless such person has a permit to do such work from that division. Division of Industrial Safety Permit No. Date Applicant CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name _ Lender's Address I certify that I have read this application. and slate that the above information is correct. I agree to comply with all city and county ordinances and state laws1telating to building construction, and hereby authorize representatives of this country to enteruponthe, above- mentioned property for inspection purposes. .e/,e %. ^"Signature of Applicant or Agent - Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the information given is correct. I�agree to comply with all slate laws and county ordinances relating to building con• �,,,,,,,,.{struclion, and authorize a representativ9,ol-the County of Riverside. Department of Building and Safety to enter upon the propertyMfoGwhichl have applied for this permit for the purpose of making in . l , f- r — SignahfP of Applicant or Agent.y t a, Date , .� a• _ Print Applicant/Agent Name