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10 LICENSED CONTRACTOR DECLARATION
I hereby affirm that 1 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 Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( )�.1; 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. 7,044;, noes & Professionals Code).
)'I exe=r Section1, rris reason
Datear gnatureaf_Uvner
-�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one. of the following declarations:
( ) I have and will meintsima certificate of consent to self4risure 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 Labor Code, for the performance of the work for whichthis
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).
( )Jt ertify 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 1'. should become.
subiect'to the workers' compensation Drovisions of Section 3700 of the Labor
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil lines 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 resuf -of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers,!agents and employees.
2. Any permit issued as 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.
J 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 authorineI representatives of this City to enter upon the
ebova•mentioned property''for-ins on purposes.
Agnature (Owner/Agel
ALC*
BUILDING PERMIT
PERMIT951Z^M9
DATE 12/18/9.5
VALUATION ?71tZ�Z, LOT TRACT
JOB 817E ADORE88
MN78-730
VY. 11<tiff LAND
604-422-00Z
OWNER
CONTRACTOR
ONVN I,R/BI-0 L,Dr-iR
RONALD l Sr, i1;ARJORIE HANNA
7873014jUd,ANU DR
i.A. QUINTA CA 92253
CBI,#
DESIONER&NGINEER
USE OFPERNUFNERAL SUj.LDINIG
FEE DESCRIPTION
FEES
KAtC'HYPNI10 14100) 5F
.
i
F-S'E'MITED COSI OF CONSTRUCTION
11,862.00
8'li.:ttM[T FI',lN: Sj(►MlYiARV
PLAN C;HT3C'i?: IFFY 101-000-439-318
CONSTR!A"110N FEE 101-000419-000
STONCY MO'IT10114 FQ - RE.= 100-00()-241-000 $.30
SUB-TOTA1. CONSTRUCTION AND PLAN CHECK
$71.45
LESS ERE-PAII3 FEES
$0.r,0
iO 'a TOTAL PwiMM[T F ',.ES 0U114,1NOW
-o
$71.45
%14AI
ey 996
RECEIPT
DATRNAI D
INSPECTOR
INSPECTION RECORD
h 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 7A
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
—
IV
Final
Final
BLOCKWALL P VALS
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
Finial
Utility Notice (Perm)
COMMENTS:
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and --- __ s• use S•-
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b.10 lot
ftw q so"
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telt w da:leyl Clan A
b- WMd. Cavinitimr. e --Vas x-'12 pitch 17/12 tri•.
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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 yourprotection you should be aware that as "Owner%Builder' yoware the,responsible party of record,on such a
permit.. Building,pcfmits.arc 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 _the_'ir license number on _all permits for which they
apply.
If you plan to-do your own work, with the exception of`variuus trades tharyou plan; to subcontract, you should be.
aware, of the following information for .your benefit and protection:
If you employ or otherwise engage anypersonsother 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�maybe 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 novcarryout these obligations, and these risks re 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 Adminstradon). 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 licensedcontractor or' subcontractor, only under limited
conditions. .
A frequent practice of unlicensed persons profess sing 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 maybe obtained by contacting. the;Contractors' State License Board in,your
community or at 1020 N. Street, Sacramento, California 9.5814.
.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.
Verytrulyyours,
CITY OF LA QUINTA
DEPT. OEBUILDING AND SAFETY
78=105 Calle Estado'
La Quinta,. CA 92253
(619),564-2,230..4
FAX=,917
WNER'S SIGNATURE/ DATE
ROEERTY ADD)M§S
PERMIT'NUMBER(s)