0203-197 (BLCK)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 ander
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). a
O I am exempt under Section B&P.C. for this. reason
Date Z -2e,. C+'"i Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one ofothe 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).
( ) !,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: 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-porrmit eubjeet to the Conditions mid realiii;horia set Ivrlli 06 Ilia
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 for inspection purposes.
Signature (Owner/Agent) Date, :Pa
BUILDING PERMIT PER MIT # d
�034.�01
TRACT
��` 3)W
TE VALUATION 1 ;Z0 ID6OT
y
JOB SITE
ADDRESS 51,-AVEFOMA WW -11141
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
P.1' DOX 604
LA QUiNTA Cad. 92253
USE OF PERMIT
J 30..k is' iLOCIt. WAUr CITY u`tANDAY-0
• A
Q:FT. WALL LP
c_! �)13JTi;UCTIONYU 101-00641-8-000;.w$11110
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MAR 2 0 2002 tj
�ifOFLAQIA A
F rowINAW ED,
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RECEIPT
DATE
BY
DA E FINAL D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
F OPERATION
DATE �
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts I
Forms & Footings
Ducts
Slab Grade
Return Air It
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U. J
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
'I POOL I S - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain li
Bond Beam
Approval to Cover 1
Equipment Location I
Underground Electric I
,Final
Underground Plbg. Test
Gas Piping I i1
PLUMBING APPROVALSEl
—Gas Test
ectric-Final
Waste Lines
Heater Final
Water Piping
Plumbing Final 1.
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation I'
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Powor 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)
.1,
i
78=495, CALLE TAM PICO, , LA QUINTA,: CALIF.ORNIA'92253
TELEPHONE (760) 7.77-7012 FAX°(760) 77 7011
FJ
OWNER/BUILDER INFORMATION
v ,R
A
Dear Property Owner:
An application fora building permit has been submitted' inyour name listing yourself as the builder of the property
improvements specified.-
For
pecified:For your protection you should be aware that as:"Owner/ Builder''' you are theresporisible party -of -record on such a
permit. Building permits are.notrequired•io'be signed by propertyowners unless they are.personally performing their
own work.,If your work is being'perforrn4by someone'other ihan:.yourself, you may protect yourself from possible
liability if that person applies f6f,'the proper permit in Itis orher.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 piir herr li'cense..number on all permits for which they
apply..
If you plan to do your own work, with the„exception of variuus trade's that you.plan to subcontract, you should be
aware of the following. information foi`your benefitan' protection:
If you employ or otherwtse,engage any persons other than your immediate family, and the :work (including materials
and other costs) %;$200,00'or,more for tl e, -entire -project, and such ,persons are not licensed as contractors or
subcontractors; then you may be an'employei .
If•,you are an employer,,youlmust, register with the'$tate and Federal Government as an employer -and you are subject
to several obligations including=Slate and ?Federal:xinco'me-tax i"withholding federal 'social security taxes, worker's
compensation insurance ;'disability.ansurance costs'and unemployment coma
pensaon,contrtbutions.
s 3 Y
There maybe financial risks'-foi you if you do not carry outthese obligations, and-these`risks are especially serious with
respect to worker's•compen'sation insurance: " ,
For more specifcinformatiomibout your obligauonsunder?Federal, Law'�contaet:the Internal Revenue Service (and, if
you wish, the U S 'Small Business,Admrrisratuon)�;For more specific info'rmat'ion:about. your obligations under State
Law, contact the'Depaitmen of Benefit Payments'.and,&e:Drvision'of lndustrial Accrdents.
2 -
If -the structure is intended,for sale,, property�owners,a+ho are not- licensed conrractots'are allowed to perform their
work7personilly or th ough'thelr own'.erriployees; without a`licensedconiiacior of subcontractor; only under limited
conditions.
A frequent practice'of unlicensed persons profeisinj�to;be coniractots is securekan, "Owner/Builder” building
permit, erroneously;implying�that,the propertyowner.is providing hi�oi her ownla6oc'and material personally.
Building peimrts are not tequtted to be signed ;6y property owKners sunless they are performing their own work:
perso""Hall"y..
Information about licensed contraciors may be obtained by con tac ing.the Coriiractors' State License Board in your
community of at 1020 N Street,, Sacramento •California 95814.
Please complete.ind returnkthe enclosed owhet builderverification form'.so'that we can confirm that you are aware of
these matters. The building permit' wili,noi be.issued until the verification is•returned:
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
+ f
La Quinta,' CA 92253
(760)777-7012 l
FAX:760) 777R,94•1 � ; ` ''
OWNER4,SkiNATURE / DATE'S'
PROPERTY ADDRESS' 1
f
06203 `/9 2 ,
PERMIT NUMBER(s)
,
CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS OWNER, W411, J .5 BUIL /2-
tr-1- lo� PERMIT NUMBER Q P',"' y /- DER c2Z-,-
This form shall 'be posted on the- job with the Building Inspection Card at all times in a. conspicuous place. Onlaersons 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
r.f k"2;1A;nr% niarmit I:r%r ant -h nnn1if-Ahlia traria all infnrmqtinn rpriiip-,tPH hpinw mimt hp rnmnIPtPfi by annfirant- "On File" is not an arrentahle resnonse.
Trade Cla imfiiLation
ContracContractor'Sltatb:Contractor's
License
Workers Compensation Insurance
CitBusiness Licenso
y
Company Name
Classification a.
License.:Number
Exp. Date,
Carrier Name
Policy Number
Exp. Date
License Number
Exp. Date,
(e.g. A, B, C-8)
fxx-xxxx)
(xxixx/xx).
(e.g. State Fund, CalComp)
.(Format. faries)
(xxixx/xx)
(xxxx)
(xx/xx/xx)
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