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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 contractingwith licensed
contractors to construct the project (Sec. 7044, Business &•Professionals
Code).
O I am exempt under Section , B&RC. for tbis reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATI.ON;;�'
I hereby affirm under penalty of perjury one of the following` declarations:
( ) .l 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).
(q 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.opi& Labor
Code, I shall forthwith comply with those -provisions?'' ^'�� 1
Warning: Failure to secure Workers' Compensate ' ov5T& is unlawful and
shall subject an employer to criminal penalt[ewand. cyyll�fp� up to $100,000, in
addition to the cost of compensation, dam`ages'as ploVided for in Section 3706
of the Labor Code, interest and attorney's.fees:y""�
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. f, i
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 i
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 fo the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forin"spe'cfion purposes.
Si nature (Owner/A ent97%''//i Date
BUILDING PERMIT PERMIT#
DATE j VALUATION LOT 0112-065 TRACT
DU 177U*18
JOB SITE
APN
ADDRESS W-148 AVEM A. D.t.
77441A.2-002
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1AtMIKEL S,0U18' VK1A Q1i
OSA sly, t r ll
g3148.FANIUMDA..M.A7,
+.
LkQUWA CA 92253
USE OF PERMIT
a a..�f.,�hERrIAL
.130 Stet 1.DSA'I'ION PER API=I:OXED PLANS
AMI.'! ON sp
Alsr ,Arm) CM OF CONSTR'UMION
13,57r 5,00
PLAN CHFICK FIN 101-000.439^318
C0731w,R 3C TIt' N 111sVE 191-000-418-000
1dEC.t3.►° ICALRE 101-0004,21-000 $2.tfa
1p:A.U.CTRIC AL, FRE 101-0001 420-000
1111UM,81-50 "IE 101.000.419.000 533.00
STKtDHO MOTION PAZ -1UTZID 101-000-241-000 U40
yr '
;i"!3s-'1°C rit,CC1i ma-TCg AIM, .[?JiumCyy'��1�?.j,t<�(1•.��FW
((�(rydy
tDF0 2001
WYOFLAQUINTA
•RECEIPT DATEI !
BY
DATE INALE
INSPECTOR
_�c xn�,
oy
r ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
Forms & Footings
APPROVALS
Slab Grade
Steel
Roof Deck
_
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath 7
Drywall - Int. Lath
_
i w/
Final _ w%
BLOCKWAL A6 PROVALS
Set Backs
Footings
Bond Beam
PLUMBING APPROVALS
Lines
Piping
ng Top Out
r Pans
Lateral
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)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
COMMENTS:
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 lawto 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.
.F,
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.
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,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quints,CA 92253
U PROPERTY ADDRESS
PERMIT NUMBER(s)
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 12/10/01
No. 22743
owner NameMichael Vasquez
No. 53148
City La Quinta
Tract #
CERTIFICATE OF COMPLIANCE
street Avenida Diaz
Lot #
APN # 774-042-007
Jurisdiction La Ouinta
Permit #
Log #
zip 92253 Study Area
Square Footage 250
Type of Development Residential Addition No. of Units 1
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 250 or $ 0.00 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid By Exempt- Michael Velasquez Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia Exempt $0.00
Check No.
Signature VitJ )�' I
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy -Accounting