0110-232 (PLBG)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 `l•
I hereby affirm under penalty of perjury that I am exempt from the Con'tractor's
License Law for the following reason:
(y;) 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#
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). r7 ��
O I am exempt under Section, B&PC�forthis,reason
Date L,, Signature 'of Owner-'
I hereby affirm under penalty of perjury one of the following declarations:
() I have and wilI.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:
Cartier Policy No.
J(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 manner4so as to become subject to the
workers' compensation laws of California,;and agree that if I should become
subject to the workers' compensationaprov`isions of Section 3700 of the Labor
Code, I shall forthwith comply with those`provlslons:' ,
Date: Applicant
"Warning. Failiir`e to secure Workers' C-ompensatioh 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 result of this applicator agrees to, & shall, -indemnify
o & 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
O permit, or cessation of work for 180 days will subject'permit to cancellation.
(.certify that I have read this application4nd state that the above information is
correct' I agree to comply with all5City, 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. f
Signature (Owner/Agent) >'�}� Dat e'
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BUILDING PERMIT PERMJT# ,
DATEqq VALUATI00 LOT TRACT
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OWNER
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LA QUINiA CA -22.5 a
USE OF PERMIT
PLUMBWO
VALUATION 1/000/90 L
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
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
SMawer Pans
O.K. for Finish Plaster
SC Wr Lateral
Pool Cover
Sewer Connection
i3as Piping
Gas Test
_
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Encapsulation
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures '
Main Service
ub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
_
<: P COACHELLA VALLEY WATER DISTRICT
CAS RECEIPT DETAIL
(pcA 9 483
t. Received From: �`'f L �Date
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Service Addres
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C "+ 0 Meter(s) v $
C) Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
1 ,
t. ❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
., Feer
❑ Plan Check Fees Water / Sewer 7-
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ID `Bond Payment - A.D. --Bond.
Assmt.
❑ Customer Deposit
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,f . •'. , . - r �� e (./� TOTAL
Remarks:
❑Copy to:
Cash Water Service _
Check
Money off " `' Cashier
38(11189)
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LLE TAMPICO LA QUINTA, CALIFORI
NE (760) 777.-7012 FAX (760) 777-7011
OWNER/ BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builderof 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 arepersonally 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, disabilityinsurarice costs and unemployment compensation contributions.
There,may be financial risks for you if you do not carryout theseobligations, and these risks are e.spe' dally.sehous 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 4020 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-eCallampico
La 92253
.(762
F-7 11
f ^'�
OWNER'S I NA RE/DATE
f14
PROPERTY ADDRESS
PERMIT NUMBER(s)