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9608-042 (PAT)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, 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). r ' O� I am exempt under Section B&P.C.//for this reason tZte �/ r �. Signature of Owner �>. WORKER'S COMPENSATION DECLARATION S ' 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 perfor . ice of the work for which this permit is issued. , r ( l 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. hoyare: 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, l.sh '11 forthwith comply with those provisions. Date: > :Applicant f �r.;� +. 7a, a'. ; r "f ` s s •.. , i t w rV Warning: Failure to secure Workers' Compensation coverage.is unlawful and `shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. I • • 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a.result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction; and hereby authorize representatives of this City to enter upon "''t. r above-mentioned property for inspection purposes. • r `SI nature (Owner/Ageht)""'`' "Date"'° r PERMIT���,�$t CONTROL# 3857 r('UILDING,E�RMIT DATE )ib4�j� VALUATION LOT. TRACT JOB SITE ...�.� .v rv.. _ .c .w APN DDRESS- ADDRESS- OWNER OWNER��II ���t }}•yy/�l t`�I' i{� X14- L:in1:ltJ"f �y.Fi VII CONTRACTOR /�D�E1SIIGNEEtRf/ENGINEER OLi/� E'R l3lJ.�Ae1�J�'R . ,18.207 V183'A. DE NO.AAL. ' LA 4;?LJ1AT.rA C.A 0253 .6 l9 -W-6558. CCF3(,-N USE OF PERMIT ol�.i��t.t � 3w .-i.4„i.L Milo v 1:. .1 4.43 0%,;,f` - iFM�'as•�-�1M • VILAN'(14i'vC FEE 51V 5141C.1iV'iO't'ION VEr-IMS]D 101:-000W.241- 0 0 Q C3 Q y,y�(�,�^t� w p� f(•�•�•�,�q CO y�-p� .+�.r �,p �y/,� PLAN 4.lLJ.G;�';1�QJ�rAL CS.J.Nlr, i� r'ai.3� l.�.i lV ;ZiLY� .i`".;,.r.�SY 1L14�.+A p�p[� �/�•� +ar.�: • 'V LESS PRE-PAID,FUS $0.00 .' TfYfA,i.! 110MA./.T.MEN 1.1 X, NO1'Y' 549-40 ' RECEIPT DATE BY I✓� DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR • OPERATION DATE INSPECTOR4 ;-. d. 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 POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. 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 COMMENTS: 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) Vii MY!�'. T..'Fl!'A.--�'••1�� Y'„'I^ X09-�,1'{W'�,T-ro!t A'Y�.`o 4..�`S{^`�• F.�iv,Y�Y-w.'w'C � wt TELEPHONE (619) 564 2246 FAX (6119)", 564-5617 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 /,guilder" you are the responsible party of record on such a �\ permit., Building permits are not required to be signed by property owners unlessthey are personallyperforming 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 . i 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 andprotection:" If you employ or otherwise engage any persons other titan. your immediate family, and the work (including materials and other costs) is X200.00 or more for the entire project, and such -persons are not licensed as contractors or 1 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 l td 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`ifyowdo not carry out these obligations, and these risks are-especially'serious with respect to worker's compensation insurance. ij 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 Stage 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 'F 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 rriaterial personally. Building permits are not required • to be signed by property owners unless they, are performing their own -work G personally. .. Information abourlicensed 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's6 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 DEFT: OF BUILDING AND SAFETY 78-105 Calle Estado La Quinta,. CA 92253 (619) 564-2246 - _ FAX: (619) 564-5617 ( (` 4:1 OWNER'S SIGNATURE/DATE —' Yl— . PROPERTY ADDRESS V • ii PERMIT NUMBER(s) .