0308-327 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
f,haeter 9 (commencing with Section 7000) of Division 3 of the Business and
7Professionals Code, and my License is in full force and effect.
t 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
(j
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 lonstructithe project (Sec. 7044, Business & Professionals
Code). ' P
O I am ez t'Llnde Section B&P..Grfor'this r song
Date ?Signature of Owner •1 -%,,iwm�'I'� """••
WORKERS COMPENSATION DECLARATION
I hereby affirm •under,ipppnalty of perjury one of the following declarations:
( ) I have and -Will md�ntain a certificate of consent to self -insure for workers'
compensation, s 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).
Wr I certify that in the performance of the work for which this permit is issued,
I shall not employeany 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 ?tir/e workers' compensation provisions�of ction 3700,A� f the Labor
Code, I,e'> II[f Jwith comply with those pr�ovisioR //
Date:(' Applicant/ 1/'�''��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject, to the conditions and restrictions set forth . on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within; 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this appli catlonand state that the above information is
correct. I agree to comply with all City, and State law$orelating to the building
construction, and hereby authorize'repreyntatives*of this City to enter upon
the above-mentioned propeerttyfffoohrisp,ec onn ur%podes. �j
S gnature (Owner/Agent) ' "�L `'/ �~ DateCj
PERMIT PERMIT#
..�8UILDING
DATE V030"27 LOT � TRACT
JOB SITE
APN
ADDRESS 15?,,,6W AY�..k`i'I(1)A 99RIMM.
OWNER .
CONTRACTOR/DESIGNER/ENGINEER
SCOTT G-AkiMA.
OWNE"i.XTLDOZ
53.600 AVENID A.IMtilkt�: A. �
LAQtANTA G •= 92253
USE OF PERMIT / `
LZ13�.0. M t.hL. AMMON/11 s �'
495 A'L'1017014 / REMODEL.
*,.CT CONS'PRUCTION 49&00 SF
I:'�'d'.�A"17D COST 03? C0.1! K9 R,1JC n0.K
CONSTRUCTION FEE 101-000.418.00E
PLAN CHWIC IeEE 101-000-439-319 $210.81
MECHANICAL 1±E.P 101.000-421.000 $26.00
ELFCTRIC,AL FIM 101- 000-420-000 $32.33
PLtiMBINO RE 101.000-419•-000 $27.00
MOND MOTION FF -V_ • R&OND 101-000-IAI -000 $3.69
SM -TOTAL CONSMUCTION AND PLA' CIMCK
$563.133
-, LESS RRFsyT'MD MW
$0.00
s
.SEP 101003
RECEIPT
By f
DATE FINALEDJv
INSPECTOR
1
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
OX 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
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
Final
Utility Notice (Perm)
COMMENTS:
'�
c(,Z
��
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/ 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 law'to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of variuus 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_ securiry_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 QUINT
DEPT. OF BUILD AND SAFETY
78-495 Calle T pi
La Quinta, 2 3 1
'S SIGNATURE/ DA
PROPERTY ADDRESS
03037
PERMIT, NUMBER(s)
•1 —.
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 53600 Avenida Herrera 495 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $0.00 X 495 S.F. or $0.00 have been paid for 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 - Scott Garcia Check No.
Name on the check Telephone
Funding Exempt
By Dr. Doris Wilson
Superintendent
Fee collected lexe d b haro M/c�Gilvrey Payment Recd $0.00
- �- ' \ Over/Under
Signature
NOTICE: Pursuant to G vernment Code Section 66020(d)(1), 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 issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting