9806-076 (PAT)U)
f—
(V U)
04 W
O M
t` Q Lf)
W
C6 Z,
�
OC:)JV�
F -a
Z
M
LO
N
ON
U °)
�a
Z
Lo Cr
r � 0
0 J LL J
U
mU
O
� 0)
It Z_
Ob 5
�O
J
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
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).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
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
perforTpee of the work for which this permit is issued.
have and will maintain workers' compensation insurance, as required by
ection 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).
() 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, 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)
Date
BUILDING PERMIT PERMIT# CONTROL#
'3ttit�s-i�7'fi A�� f ��
(01DATE � V98 VALUATION iW.168-70 LOT TRACT 7 8 ���qqq
JOB SITE 7-495 CALL111; 1141.1. AGO APN _ t
ADDRESS
OWNER CONTRACTOR / DESIGNER I ENGINEER
`Eai M. F"IR ING iti. 10ivrNER Will .1
.P.0 BOX i6l SAME
�
I.A. QUINTA. CA
Cf`LI.
USE OF PERMIT
Pil r10
y,i `.St,1.i~T l",il i�t}►'f"s eCd�.ti��it°iU C
e•ty.i2Cies.l A'.r @O 5.s9.0J 115".
4T`:.AIATED COST OSI, CONSTRUCTION
A°�-4'.xet- M41 �! �b °
101-000-439-3118 $164.35
11114)(91-08-M) $9%oo
:3{'R{3t3G.1`YJr�`�.v f.J.ii VE ,101 •050-241-000 S./2
$ x - - - —' — — — -
Y
6" fir. (nA1. f 0?! 1RUCIJON AND {'lrAN CHECK 64 {) t
U Is PRE -PAID MOS,
JUN 0 5 1998
TUFA f, PERM TFEES':90, NOW � S464-407
(OF LA �UjNiTs
RECEIPT DATE DATE FINALED= ":ar INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
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:
'
r
5v
.��l � '�
/�
� � W
Xz
I HKIT�- -► i
RTNIENT j
BUILDING. & SAFETY ®EPA
CO
NDITIONALLY
c ACCEPTED FOR CONSTRUCTION
SUBJE�YF TO INSTALLATION AS PER _ .
AND ALL APPLICABLE CODES
BY
f
-1998 13:04 AAA LA QUINTA
Fhm
Carpel
i.vc�dZ K L.2S
Fu 1
_ . osposr;on:
Cus't6'
760 771 0045 P.01
saes, Ony/zsJ48 '...I •.�i'r�.
N ow I E . FowLE2
AUT
O. CLUB. $0-.0 ALIF
LA OU:.NTA.
161y- 7:1-0045 .(619) 771-1.162
C)Dmw . C]R . IIcxapcaq
CvvE z)gGc-S A 7'TR�CS�/EQ7
,INTEFiINSURANQE EXCHANGE of -the
m� Automobile Club of. Southern California
MEMBER'S DELUXE HOMEOWNERS POLICY—FORM 3
r . ; TYLE OF CONT101TS'
' 1 . a.ml awed 7 WNal Nam we fywftd 14
Y >n tastwad i wW Num an sit t�tafal .. 14
• : , Mal Ism, n tact taasl 1
IEFIBITIONS
KNERAL PFAVM 15
Miq prig ' .: ... a
LtiKaNbnl gr fraya
Ttirfel'sdloe' ' a
fAaspes and IberaLratin a
irtimhr er udgmeal . �a
Wilatin 4
S111sia nls in Ola ttI I' —isn for
Isseram . . . . . . . .4
PART 1—PROPERTY COVERAGES
COVERAGE A-49ELLM
COVERAGE 1-4TNEA STIUCTOIES
What prsporq is cewrttd 4
Wht �repatir K sot alto A
WAat oltsm m tamed 4
OT11E1 COYFAASES.-IIANT I
fess of ew1
tlasronl of bum uses10
. atlf
Tressutis ad off r "Is' 10
iba a team 10
COTNi1Al� E�uC
PRYINEM TO OTOWhat Nam m env" v" 15
MW Imam No Mt wMed .. 15
dopsuns t Alltriolu P 1
(lameml at tklris sad tnkuaslt rc
es17
ti 10 F�aldupsm . . . . . li
lselital s1 prsportl 10
lfauesallN it�airs 10 to Inlah oft li
fnyrlT leeoted. 10
(1fo011 card, -few bsuw Call.
f Illy Mb pt�tlrgit CpRO(T101a--W n li
tsasp it ....
PART 01•—WORKERS' COWE11S16
IOARAITEE11BlApENE1T TO ANO OPIOTERS' EIAILM
COST=INKY 1 I1 fOUMSE F—WOa1M
paaffmvemnu
AfrF 9--tlDl� 1N14DT
What Nasal m trot tatm0 . 1
What lasses nes awned . . 18
'.CORORIOMS=�IAIi t . . 11 Wqt Itlttos srs set q>ranl t1
COVERAGE C- nWfuI IIWPERTY.
Mat proportt is tamed . / PART i{rllA11l1TY COYEAA6ES . CONKMIS—FAIT 11 ... 19
What pr" is c mad o6jad
11 N arLu wiv" UWU 6 0--161i0MAl L"LjTT E11501SEAMM . 20
AGREEMENT
srh'will provide the blbtirarr09,daee;ittied.in;00$611cy In return for t116 premium due ut and compliance vdth all
applicable provisions o1 this policy Includingipy,endorsaments. Your.eovernes appear on the attached decimations
page which is apart of your policy. The declar"ons page tl+ors d» poRcy period, the promises to which NIS insurance
applies• your coverages, No types and amounts of your "itrance and your premiums.
M1K, m� Includes copyrighted material of Insurance Sendces Office with its permission.
2-d Eo.—.9s; Copyright InawanceservicesOf e. Inc., 11984
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 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 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
land other costs) is $200.06 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.
i 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
,, L`a7w, 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 (760) 777-7011 1
V
OWNER'S. SIGNATURE ATE
PROPERTY ADDRESS
PERMIT NUMBER(s)