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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:
(l 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).
() I am exempt under Section B&P.C. for this reason
Date it " � '� � Signature of Owner" ,{,.-,111 E. I
WORKER'S COMPENSATION DECLARATION °
I hereby affirm under ,penalty,;of perjury•bne 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:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(4 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: t•s! 1 .ti Int Applicant ^';fir.`•, ,' t ; r !+ ;1 f_ ��,f. ttJ./
Warning: Failure to secure Workers',/Compensation covarage Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) C �,_ �. H / \f Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (�� TRACT
rof 14 3,3520
JOB SITE
APN
ADDRESS
44-425 rMYrAn, c, M19`
-tN: "12
OWNER
CONTRACTOR / DESIGNER / ENGINEER
P1191f & GAIL, AAi•1JMGI
dVr. RIDM
44425 MKTAM OR
LA QDTAI 1'A. 104A 512253
03.14
USE
yOF�PERMIT
d�3:.A�1L��tl d.'4�slr tSAJ.�%1,.6,tt!.t\i
764 3PA00)"Tf.M P.E'R APPR0V' .rl-,Ai4S I
ADDITION 8F
FISIT"MID MIST OF CONOTMIX.Mobi
14,1M.20
MMU YET. RI3MA"RY
'1k1 f'I$N'C� FI:a3 10 1 ti(Maeti, 3 18 $10:1,.3D
t,C3?dS°PRUC` X)14 VEW 1131-CiW-418,000 $162.00
Fs"f°ROM MO'T'&ON PER - R MID 101-000.241.000 $1.43
;1„T'CTRI ICA1, I� 101 15(0,00
a �
D
APR 10 2001
CITY OF LA OUINTA
FINANCE DEPT _
$298.73
wl�f FST' '-PAE'L) %�'„L�-°aJ'
T10:oo
"f 10TAL t'MM EMITS .$SUE NOW
RECEIPT,., ,
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-I?5!?,
Ducts
Slab Grade
I
Return Air
Steel
t
Combustion Air
Roof Deck
Exhaust Fans
b.K. to Wrap _ _
Framingr
F.A.U.
Compressor
Insula)ion
_ _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls _
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/
Drywall - Int. Lathi
�U
Final
Final,1�'
3p-p� `J�
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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 APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.FJL41,
Smoke Detectors
Temp`Use of Power
Final
Utility Notice (Perm)
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 4/10/01
No. 21868
owner NamePhil & Gail Anderberg
No, 44-425
city La Quinta
Tract #
Type of Development
Comments
Street Foxtail Circle
Lot #
Residential Addition
APN # 604-084-012
Jurisdiction La Ouinta
Permit # 0104-073
Log #
Zip 92253 Study Area
Square Footage 264
_ t
No. of Units 1
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:
r..
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amounQf
0.00 X 264 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 Telephone
Name on the check
By - Dr. Doris Wilson
Superintendent
Fee collected /exempted by Olivia Aguirre Exempt $0.00
Check No. N/A
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) 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
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.
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 Quinta, CA 92253
(760)777-7012
FAX (7 777- 11
E S SIGNATURE/DAT
PROPERTY ADD SS
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