0004-252 (BLCK)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:I
( ) 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).
O I am exempt under Section , B&P.C. for his rea n
DateOV Signature of Owner
7
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
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).
( ) 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: ADDlicant
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 authoriz represe tatives of this City to enter upon
the above-mentioned property fo Ins eecctd' n �rposes.,
\S(nature (Owner/Agent) I,Cd /i ac iu-°tip- Date 2y ou
BUILDING PERMIT
PERMIT
�r25
DATE VALUATION LOT
ca�ir liat� $2,5"A)O
TRACT
JOB SITE
APN
ADDRESS') 51.52.0 LUSKNHOWEIR,Ma .
OWNER
CONTRACTOR/ / EN (NEER
RODP1GU.Z WHOM
O•�.ti31=ER
51-:510 k-.0 .-IOW-M DRIVE
51.310 M_-'NH0)M Dfi
LhQZ:T=A OA 92233
f.AQ13INTA
CA 92233
(350)584.0834
C$L4
USE OF PERMIT
GMr17+ ML BU.0 ZW(+
S.LO& 'iAt'ALId 120 L.P. @ 5' H1QH
i
5 FT. WAIL
120, 00 LF
ES"1'1A'ZED COST OF CON91"RUMON
209.00
PERNEf FEE 91J; ARY
COMTRUCTION FEE 101.DOO-418.000 $54.00
• i
tri
ti .
StJ13-TOP1',AL C'C3N STRUC7109 AND PLAN G":E- FCK
$54.00
1:235 PPE -PAW n, "93
$10.00
W,r0 A.1i PMi;'D:''i .E.5 DUE NOW
$54,00
RECEIPT
DATE
.111
BY
��lt` .�•
D FIN LE
'o • oma.
INSPECTOR
t
INSPECTION RECORD
l
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 j -
OX to Wrap F.A.U. I
Framing Compressor I
Insulation Vents I
Fireplace P.L. Grills I
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall j
Exterior Lath I
Drywall - Int. Lath I
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Final
Final
BLOCKWALL.APPROVALS
I POOLS - SPAS
steel
Set Backs
Electric Bond
Footings o-
Main Drain j
Bond Beam S7
Approval to Cover
Equipment Location
�-
Underground Electric -.
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final j
Waste Lines
Heater Final j
Water Piping
Plumbing Final j
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation i
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Notice
I
Final
COMMENTS:
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
TemD. Use of Power
Notice
I
Final
COMMENTS:
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
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: 60) 77 0 1
) —U6
OWNER' SIGNATURE/DATE
PROPERTY ADDRESS
nao L-1 -OZ5a
PERMIT NUMBER(s)