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9706-013 (PLBG)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 ProfessionahrCode, and my License is in fiull force and effect. License # Lid. 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). 11. am exempt under Section B&P.C.• for this reason Date 1f11_lferl Signature of Owner. J. t -t A, f 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. ( ) 1 -have and will,., maintain workers' compensation insurance,.as required by Section 3700 of the Lbor 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 -$1 00.00.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, 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 $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth* on his application. . 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under,or pursuant to any permit issued as a result of this applicaton agrees to, &.shall, indemnity & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180. days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with.all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property forinspection purposes. Signature (Owner/Agent)-KMA/.j/N— Date �r'{I4� ri�f .. PERMIT# CONTROL# (G BUILDING �� 9706-013 5266 DATE0.' VALUATION S,500.00 LOT TRACT 419 JOB SITE / /'� J ADDRESS. APN OWNER CONTRACTOR/DESIGNER/ENGINEER Alt 'IT"eI Q 01.JVA,,KFZ Get'• VIR.13U:1IDEI S1-975 AWWDA i/ILLA 51406.AVEN1.1"),f1 M.1rNDOZA. 1,,A,%f.31r1TA, CA, W2.253 LAQUINTA CA,.92253 USE OF PERMIT N Jim 6 15147, OF GA 9 O.N 500.0 ki 1:. ; PLUMBING 1,13P 101400-419-000 .$-10. 0 "Al Q��riso-'r1�9j��sC,'•f7/A1;�,"T'!�.4.JC:"T,'Tflid a'�h1 C11k•'f�.+, f1y`A3 C.'}1.�C`i'E�', �+(�E�1.a��0 y-� t EES �l..tit/.1Hj' x RECEIPT DATE BY.. 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 Wall Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground PI . Test Final I I 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 COMMENTS: Final Utility Notice (Gas) ELECTRICAL AP ROVALS 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) j J 44 0F TEl$�wSw 78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253. TELEPHONE (760)777-7012 FAX (760) 777-7011 OWNER/BUILDER INFORMATION Dear Property Owner: An application form building permit has been submitted in your name listing yourself as the b�iilder of the property improvements specified. For your°protection you should be aware that as "Owner/Builder", you are the responsible par -,,y 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 requiied bylaw to be licensed and bonded by the State of California and to hive a business license from the City .or County. They are also required by law to put'their license number on all permit's 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 beneht and protection: If you employ or otherwise engage any persons other than yourimmediate family, and the work (including materials and other costs) is $200.00 or. more for the entire,project, and such persons are not liceneed as "contractors or subcontractors, then you may bean employer. 'If you are an employer, you must register with the State "and Federal Government as an employer and you aref 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 Re`.enue 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 unatcrial 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 Quinta, CA 92253 (760) 777-7012 FAX (760) 777- O1 ' AgOW� OWNER'S SI ATURE/DATE I . e?o(o preen ek Meneto za_ • la uirdei � (A 92Z5 3 PROPERTY ADDRESS 7d 01 3 PERMIT NUMBER(s) 5 I