0108-0216 (AR)49151 Avenida Anselmo
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 70y) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
It F3 7433/03
Date Signature of Contractor
— .0 ;_ ,• , ,, d
OWNER-BUILDER'•DECL"ARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
A) I, as owner of the property, or my employees with wages as their sole
bmpensation, 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 ficensed
contractors to' construct the project (Sec. 7044, B6siness Q Pr ssionals
Code). f 1f d
( ) I am exempt under Section , B&RC.ff r his r 2sc
Date Signature of Owner / <
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 3700aof the Labor Code, for the
performance of the work for which this permit isissued.
( ) I have and will maintain workers' compensation insurance, as required by
S,ect'pn 3700 of the Labor Code, for the performance of the work for which this
ermit 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 subiert to the
workers' compensation laws of California, and agree that if I should )ecome
subject to the workers' compensationp6visions of Section 3700 of the Labor
ly Code, I shall Iorthwith complyth t e provisions.
Date: pplic a .-
"—•Warningr^FaituYe 'to secs e• b - ompensation coverage is unlawful and
shall subject an employer to criminal enalties 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 6
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. r
2. Any permit issued as a result of this application becomes null and void if l
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 f this City to enter upon
the above-mentioned property foninspectio7pugo es.
Signature (Owner/Agent) ADate
PERMIT #
BUILDING PERMIT ``,:
DATEhf VALUATION LOT !j $- TRACT \
A t X ) Vii... -^''r $12,011=
JOB SITE(, f __%APN
ADDRESS r-
4.
+_ /
$tr1'• .y,1 AVEMDA AN -Ti i1 le?V
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
DAWy.11AyYx`
A`qMr 0
LA.QTIWXA t,,A X121,33
r - C° L10 189
R
USE OF PERMIT
90 . F AVDI'x'2OV AZ ?dt. OK AN"D WE'T RAP AT ORBA.'T Y,00M
CUSTOM t.ONSTH.ii01021 90.00 3F
VALUATION S,G00.00 I:..s
FIAIRMf 11 1130.1 AiMMARY
RLAN CHE= PFX 1014)OO-4,9.318 $102.96
VC114 TRUC'TIGN FX9 101-000.419-000 $144.00
MECHANICAL, F19F, 101.000.421.000 Sig,"
&.I GTR),CAi,110% 101-000-420-000 $113.15
M.,.i.1MLilNs;51T1? 10 1 -000-419-0 90 124.00
3T.fCONO MOTION FXV? • 11ESID 101 -000-241 -000 $1,20
;
;aF3i3 '.iCY3 F C 23'. t3'z "COR Aka) P1<. kr l c'`%31:+.c.k
$309.81
YXISS PRE.—P.ArD 7.793,
e
$0,io
AUG 212001 -
CITY OF LA QUINTA
I IIIIIII IIIII III I II III 68
FINANCE DEPT.
IE
RECEIPT
DATE f
BY
DATE FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings ZZ p'
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 9 g aL
Irrulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Fdrty Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath
Drywall - Int. Lath
Final
Final . ' ' ! — y —
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
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
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.
�C
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
�j 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 Stare
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 Cal ampico
La Quin 92253
(760) 77 - 012
FAX
(7 -70
O ER'S SIGNATURE/ ATE
f,67 A4-1::;; XJ 04 ZS
PROPERTY ADDRESS
PERMIT NUMBER(s)