9606-001 (PAT)S 1
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
Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Licefise Law for the following reason:
(. I, as owner of the property, or my employees with wages as their sole
crmpensation, 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. fcwthis reason.
Date t; ` 3`� Signature of Owner A
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:
Cartier Policy No.
(This ction need not be completed if the permit valuation is for $100.00 or less).
(q) 1 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
subjegt to the workers' compensation provisions of Se do 3700 of the Labor
QCo e; I shall forthwith comply with t 3se provisions.
te: �� � Applic -�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to.$100,000; in
addition to the cost of compensation, damages as provided for in Section' 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person. at
whose request and for whose benefit work is performed under or, pursuant -to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction,and hereby authorize representatives of this City to enter upon
Jignatuabove-mentioned property for inspection pur os
re (Owner/Agent) Date U
PERMIT # CONTROL #
BUILDING PERMIT. 3417
DATE a1I 319CO VALUATION '.3,±37.x1) LOT. TRACT
JOB SITE 53-.1613 t1,V1^�;NWA VILLA
APN 774-064-007ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MW ER. OURIDE
53.160 AVENIDA WIIJ A.. .
J:, A QWN`C•A CA 92253.
CF_31,#
USE OFPERMIT
1'.f1�`i'Cj •
A.
EST.B MNMO COST OF C'`ONI S.Cl$CJC'.CION
PERMIT FEE S111MARV
PLAN CREC."K,.f'` E. 101.-0(*- 4393.tE2 $40,95
CONS r:�.LE<:'t" OK 11 1119 1014)i;-418-000
'4�4,Ci'i'1.0t` FVt - W3.4(1) 101-000-241-660
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Sub-` x16' -L CONSTRUCTION AND PLAN CHECK
1 f;..SS n:&8 4*1A(U F L". VS
$0,00
'C''i'AB�;E':3±Fil►�(`I' F`,'H, L3UP'NfJitT
$:0.4.5
RECEIPT .'DATEBY
3/f . j
DATE FINALED
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
J
Final '
Utility Notice (Perm)
COMMENTS:
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AND ALL APPLICABLE CODES I .
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OWNER? BUILDER: INFORMATION
Dear Property Owner:
An,application for a building permit has been submitied in your name listing yourself as t -ie 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. roperty owners unless they are personally performing their
own work.. If your work is being performed by someone -other than yourself, you may prosect yourself from possible
liability if that person applies for the proper .permit in his.or her name:
Contractorsare 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 :ill permits foi which they
apply. `+
If you plan to do -your own work, with ,the exception of various trades that'you plan to subcontiact, you should be
aware of the following information for your. benefit and'pro"tection:
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 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,tax withholding, federal social security taxes, worker's
compensation insurance; disability insurance costs and'unemployment compensation contr.butions.
There may be financial risks for you if you do not carry out: these obligations, -'and these risk: are.especially seriouswith
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.
ifthe 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 "-Dwner/Builder" building .
permit, erroneously' implying that the propertyowner 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 coiitaciiiig the Contractors' State License Board in your
community or at 1020.N. Street, Sacramento, California 95814:
,Pie ase complete and return the enclosed owner -builder verification form so that we can coifi_rm 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
DEFT. OF BUILDING AND SAFETY
78-105 Calle Estado
La Quinta,. CA 92253
(619)564-2246• .
FAX: (619) 564-5617
OWNER'S SIGNATURE /DATE:
PROPERTY ADDRESS
?606 00 1 -
PERMIT NUMBER(s)