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0105-261 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 5°(commi}lcing 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: �cI, as owner of the property, or my employees with wages as their sole ompensation; 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). O I am exempt under Section , B&PSC for this reasonA Date 4� -Cal Signature of Owner ... �-� —� 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 insurahce; 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 section need not be completed if the permit valuation is for $100.00 or less). (_,)Il 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 thprovisions. Date: �' ` 't t: Applicant---/, 1. 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. IMPORT-NNT 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 Ouinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if eR 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 construckgri, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purpo� Signature (Owner/Age ri�) ' ;.V- Dle' s 0 ► BUILDING PERMIT PERMIT# DATE VALUATION LOT ()j -j151 TRACT JOB SITE APN ADDRESS OWNER CONTRACTOR / DESIGNER / ENGINEER -SrfFJn.*'W t1+T'001WFARD S`1F111k1m WOC3i3l1il'A D 4g -45g DEMUROOK M, CLE 45.455 DEi.�E�F?l'R«G A C1ai. X E? LA QIJ113 l P. C'A. 92233 1A QTJWTA 92253 C/60).345-51°8 C"`<lIX USE OF PERMIT 41001. *WJO12 Lcy*PA POOLISRA. AL.ARM1111i3ARRIERS simLL rip: tN PI ACC AT P"v,PI..PtS'f ER, (MP Cf ION. POOL Fk)UIPMFKT R�1X,l,C -AIRS WT MCI.UDE ID, POOL Ar1:Cy!{.:►1R SPA. W00.001_ F7IWIXD C06 T' 01F Ct)SVUZi'd7:"6,11i1IO.N 1 �,CsCD 42D PLA14 CHECK FF% 101.000430-318 WAS CGHSTt3?ICTION VFW 101-000-419-000 $153.00 MECHANICAL •- P001, 101.-000.4.21-rK* 324.00 371. ECTRICAL FEE — POOL 101-OFIG-420-000 $415.(90: PLtIAIIRIHO FRE:.. POOL 101.000-419.000 $27.00 t7't.(�,Y,.+�©iti""C"'.11rG"°IYC9.1+1 A i7 Ia�N C ti".It $348.41 0 U� 1-: .l .r.4 a�'VMW F-F,CSs DI +' NOW ,[7A Y 2 3 2001 0111' Of LA OUINTA BY DATE FINALED INSPECTOR I N §WIM061 UR EOW .RI OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR [AMONG APPROVALS MECHAMCAL 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. I.ath Final Final BLOCK -WALL APPROVALS Steel Set Backs Electric Bond Footings Whin Drain Bond Beam Approval to Cover Equipment Location _ Underground Electric Underground Plbg. Test Final Gas Piping PLL,UMLE3��1' G APPROVALS Gas Test Electric Final _ Waste Lines Heater Final _ Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K for Finish Piaster Sewer Lateral Sewer Connection Gas Piping Pool Cover Encapsulation 011— W-1/ 4 A F '0009- � Gas Test Appliances 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) Final COMMEMM 45455 Deerbrook Circle La Quit., CR 92253 6' High Block Wall 6' High Block Wall Pool Equipment 4' High Fence 10' Grass 27' Sliding Glass Door Rej 17.5' A 3'6" Deep Self Closing Latching Gate HOUSE r Pool 18' - 28' .1 MIMI cel.,vicolm CONTRACTOR cannot assume monsibility for P �:F, •-11.x- • curbs,.'mdnveways remed, slabs,- - 1 - 1 = 1 1 • • valls, sprinklerstel-p1.1- 1" • Ir.• 0 When c made through a / ' • 1 0 • -_ ■ .ice®�r`i property understood 1 , • the • 1 -FIRMING] 1 - - t hat neighbor's permossion and 2ssiime responsibility,B' n. D`„*signature•��_ � CITY OF UI TA i3U G & SAFETY D PT. APPROVE FOR CONSTRUCTION DATE �2,5 A RE -INSPECTION FEE OF $30 WILL BE CHARGED IF THE APPROVED PLANS AND 106 CARD ARE NOT ON THE SITE FOR A SCHED LED INSPECTION. NO EXCEPTIONS! 71 SPA 81 6' High Block Wall 3'6” Deep 2' Concrete Deck 11' 10' MOTOR HP HP FILTER -5 `- r SQ FT FILTER RATE !&O GPM Kt I UKN LINE) SKIMMER MODEL CHECK VALVE C i1Cr un t7 i d GASLINE BYr9 POOL LIGHTQur*,4 CLOCK ELECTRICAL BYO C kexFT_ STEP - FF. SPA SPECS. SIZE ISED 17)T— LITE' LITE' 1 0 ' WATTS RI LEVEL SEATS. DAMWALL` . Z X DAMWALL_TOP:: , SPILLWAY SIZE ." X WIDE SPILLWAY OPEN -CLOSED 4E IGTC U 9 I IDFR .71 nwr:R 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 arc the responsible party of record,on such a permit. Building permits are not required to be signed by property owners unless they arc 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 arc 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 rax 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 .arc 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' Stare 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, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico la Quinta, CA 92253 (760) 777-7012 FAX (760) 777-7011 ER'S SIGNATURE/DATE -LloS b Eco-�%-Zzo�c- C A rte e.. (,-,& PROPERTY ADDRESS /n/ as-- 2 NUMBER(s) CITY OF LA QUINTA SUB -CONTRACTOR LIST JOB ADDRESS `fSS SEER �+C 6- cif PERMIT NUMBER 0105--Z&/ OWNEi,."D BUILDEF This form shall be posted on the job with the Building Inspection Card at all -times in a conspicuous place. Only persons appearing on this list or the 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 st of building permit. For, each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable respo Company Name Classification License Number Exp. Date I Carrier Name Policy Number (e.g. A, B, C - S) (xxxxxx) (xx/xx/xx) I (e.g. StateFund, CalComp) (Format Varies) N ,r -(Z—