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9707-139 (RPL)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 C0 de, and my License is in full force and effect. cy) bc. Class Exp. Date LO Date Signature of Contractor C=) (D OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: '.-(- ), 1, as owner of,the property, or my employees not wages as their .sole' - -compensation, will do the work, and the structure is not intended or offered for- salp (Sec. 7044, Business & Professionals Code). I, as owner of the property, am exclusively contracting With license , d c6hti`Act6rs to construct the project (Sec. 7044, Business & Professionals ode) C0 I a exempt under Section B&P.C.,for this reason LO -A S � x I exempt k, I I �(v 11 � �(;l -. , -n (I c\I bate Gianature of Owner C\I 0) WORKER'S COMPENSATION DECLARATION Z I hereby affirm'under penalty of perjury one of the following declarations: 0 O 1 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 Q -J performance of the work for which this permit is issued. I have and will• maintain workers' compensation insurance, as required by Secti6h. 3100 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. t--,711777 MOM= 1 1* 0 (hissection 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 SAj6ct to the workers' compensation provisions of Section 3700 of the Labor A6ode, -11.s all fort with comply with �those p ovistons. ons Me. App—... Warning: Failure to secure Workers' CoMpensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to-si 00,0bo, in ' additionio the cost of compensation, damages as provided for in'Section .3706 of th6Labor Code,' interest and attorney's fees.' IMPORTANT Application is hereby made to the Director of Building andSafety 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 pgrsow'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. 1. certify that I have read this application and state that the above information is correct. I agree to comply with all City, and S&te laws relating to the building cons ruction, and hereby authorize representatives of this City to enter upo the i, above-mentioned property for inspection purposes. I S 'Sgn.ature (Owner/Agent) —Pit I- n(A(X10 Date �?1 PERMIT# CONTROL# BUILDING PERMIT5619 DATL�-,.7 "n,097 VALUATION LOT TRACT +7"%.43-33>_0... a JOB SITE 52-F. �S,AV N111 A VILLA, 7.43-3.07 ADDRESS JAPN OWNER CONTRACTOR DESIGNER ENGINEER -A-A QjAN' CA.: 92253 CIM USE OF PERMIT F i� MRO;A$1�q POOL 0,N i' WO FGiXVL-R. it POOL MAXOR SPN Ls a cao,mwv. inxq SO M17:rRICAL F01, ­P041t. 10'. K.107N.MiNrorM, POOL 10i -OW 419446 40 TV"SUR-TOTLAIId 7 , -N87 4.14KMON. 2v1"= AN GRECk A $2. 20 USS PRE Afl F S TOTW�TEKMIT FER901JE Wo,� JUL RECEIPT DATE 11*i BY DATE FINALED INSPECTOR "OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS 4 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 BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final f Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K for Finish Plaster ' Sewer Lateral Pool Cover 144 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 Final Utility Notice (Perm) COMMENTS: de., CAuX lG/ 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 protectionyou 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.'o have a business license :from the City of County. They are. also required' by law to put their license number on ail 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' 4If 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, thenyou may be an employer. If you ate.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 a.re especially serious with respect -to worker's compensation insurance. For more specific information about your obligations underFederal Law, contact the Internals Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about you; 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' StaF.e 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 verificationis returned. Very truly yours, CITY OF LA QUINTA _ - DEPT. OF BUILDING AND SAFETY 78495 Calle Tampico La Quinta; CA 92253 (760) 777-7012 . ' FAX: (760) 777- V. �- - 7 / a .7/ 9 OWNER'S SIGNATURE/ DATE 5a�o5ViliQ PROPERTY ADDRESS PERMIT NUMBER(s)