0204-006 (ELEC)LICENSED CONTRACTOR DECLARATION-,i'-
I
ECLARATIONi
rl hereby affirm.under penalty of perjury that I am licensed under provision's of
``Chap1er'9 (commencing with Section 7000) of Division73 of the;Business acid
Professionals Code, and my License is in full force and effe, x,
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
Lice se Law for the following. reason:
.(;7I; as owner of the property, or my employees with wages as their sole
compensation, will do the work,.and the structure isI,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):.'
( 0.m"Ri exempt under Section ; B&P.C. for this reason i ..
ljate Signature- of Owner
WORKER'S COMPENSATION DECLARATION
I hereby, affirm .under penalty 'of, perjury one- of. the following declarations`'
"O I have and will maintain a certificate of consent to self -insure for workers' r
;compensation, as provided, for by Section 3700 of the Labor Code, for, the
performance of the work for which this permit is issued. ,
r { ) 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 ihe'permit valuation is for $100.00 or less).
(z,)"'l oertify,that in th6$drformance of the work for which`.this permit is issued;'
`I shall not employ any person in any manner so'as to become subjecf to the
;workers' compensation laws of California,, and agree that if l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
'"Code, I. shall forthwith comply with those rovlsions.
ate; `� 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 37.06.
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 .restricti6ns..set forth on his,
application:'
1. Each person upon whose behalf thi's application is made & each'personat
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• issuedas.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 ,y.
correct: I agree to.comply,with all •City, and State taws relating -to 7.the building
construction, and hereby authorize representatives of this 'City to enter, upon
.the above-mentioned property for inspection purposes.
,Signature (Owner/Agent) f.� = " " ':Date
_ h
4 r: BUILDING PERMIT PERMIT#
.
DATE VALUATION LOT,' TRACT
'
,
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26152
JOB SITE
APN
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ADDRESS (•ji'P`°845 VLA. C�X
1
'OWNER
CONTRACTOR/DESIGNER/ENGINEER ?.
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-81.5 VIAWIM0
.L&AUDITA CA 92233
USE OF PERMIT
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RECEIPT
!
BY
D INAL
INSPECTOR
J.DATE
AP
10 1)7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
w BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air t
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 8 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
:5— Z
Appliances
Final
Finallj_ _ Z�
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:
'
/
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. f
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 potection:
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 issueduntil the verification is returned.
Very truly yours,
'CITY OF LA QUINTA f a
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta,, CA 92253
(760) 777-7012
FAX: (760) 727-7011
OWNER'S SIGNATURE/DATE ,
PROPERTY ADDRESS -
PERMIT NUMBER(s)