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10-0894 (PLBG)'_# . '., J P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: \16'-_00000894, Property Address: 80691 OAK TREE APN: 775-082-034- - Application description: PLUMBING Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 400 c&ty/ 4 stP Q" Applicant: Architect or Engineer: BUILDING & SAFETY DEPARTMENT BUILDING PERMIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760)1777-7153 Owner: FULMER SCOTT 80691 OAK TREE LA QUINTA, CA 92253 ------------------------------- Contractor: Owner Date: 9/13/10 L=J WORKER'S COMPENSATION DECLARATION ZCL O C'V I hereby affirm under penalty of perjury one of the following declarations: Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. 3 G _ _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided � w r -r a a LJ U.) t �- _ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor -----------------------------------'-------------------------------------------------------------- LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations: Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. _ _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided License Class: License No.: for by Section 3700 of the Labor Code, for the performance of the work for which this permit is - issued. Date: Contractor: _ 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 OWNER -BUILDER DECLARATION insurance carrier and policy number are: Thereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the Carrier Policy Number ' following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to L"I certify that, in the performance of the work for which this permit is issued, I shall not employ any construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the - person in any manner so as to become subject to the workers' compensation laws of California, permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State and agree that, if I should become subject to the workers' compensation provisions of Section License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or - 3700 of the Lab Code, I shall forthwith mply with those provisions. that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: Date: % Applicant c ( 1 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 and Professions Code: The WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL Contractors' State License Law does not apply to an owner of property who builds or improves thereon, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND and who does the work himself or herself through his or her own employees, provided that the - DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN improvements are not intended or offered for sale. If, however, the building or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. _ one year of completion, the owner -builder will have the burden of proving that he or she did not build or } improve for the purpose of sale.). APPLICANT ACKNOWLEDGEMENT (_ 1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application. - property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 1 . Each person upon whose behalf this application is made, each person at whose request and for pursuant to the Contractors' State License Law.). whose benefit work is performed under or pursuant to any permit issued as a result of this application, 1 1 I am exempt under Sec. B.&P.C. for this reason the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City _ - of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. Owner: 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 CONSTRUCTION LENDING AGENCY permit to cancellation. I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify that I have read this application and state that the above information is correct. I agree to comply with all work for which this permit is issued (Sec. 3097, Civ. C.1. city and county ordinances and state laws relating to building construction, and hereby authorize representatives ' of this county to enter upon the above, -mentioned prrty for inspection pur Lender's Name: Fr � ( —1 Date: `-/ J- `,---%nature (Applicant or Agent): Lender's Address: LQPERMIT Application Number . . . . . 10-00000894 Permit . . . . . PLUMBING Additional desc . Permit Fee . . . . 18.00 Plan Check Fee 4.50 Issue Date . . . . Valuation . . . . 0 Expiration Date 3/12/11 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 3.0000 EA PLB GAS = PIPE 1-4 OUTLETS 3.00 -------------------------- Special Notes and'Comments ------------------------------------------------- INSTALL GAS LINE.EXTENSION PER,APPROVED PLANS & A.J. ---------------------------------------------------------------------------- Other Fees . . - . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid -------------------- Credited -------------------- Due ----------------- Permit Fee Total 18.00 .00 -00 18.00 Plan Check Total 4..50 .00 .00 4.50 Other Fee Total 1.00 .00 .00 1.00 Grand Total 23.50 -00 .00 23.50 LQPERMIT P.O. Rox. 1504 LA QtJ[NtA, CALIFORNIA. 92247-1504 BUILDING & SAFETY DEPARTMENT 78-495 CA[:LE TAMPICO (760) 777-70.12 LA .QUINTA, CALIFORNIA 92253 FAX (760) 777-7011 PROPERTY` OWNER'S PACKG }isctosures & dorms for 4wnter B.nIders. AxI"9r Cottstrctioaermis .. , .�P�GiR�"�.11t�'1 NOTICE TO gRt1PEBTit OWNER ' Dear Property Owner n appiieatiou fora building permit has% beew.submitted. in your name listing yourself as the builder of the :property :improvements specified atm c,Cta / �m k T'.« Lg � TT CA pz� We are -providing you v►itlr an Owner -Builder Ackno d t and h matien erification.Form to make you awase.of your. rtvlmibilities-andpossible risk -you may incur by having thispernut-issuo lwyour name as the Owner -Builder. We will not issue a buiiding.permit. until-YDu•t[ave read; initialed your. understanding.of eaeh`provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this'.notice unless you, the property owner, obtain the prior approval of the permitting authority. OVRMWSA OM!EDG NF AND,WRMCATION,dl'Il (?11VIAiT At ARMT--ONS: Read and utitial eachstatement belaw td`signify you undwstand`orvwify this'informatiion. QCEL I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" uddmg permit that erroneously implies that the property owner is providing his or her own labor and material persc r AY.1, as an Owner -Builder, may be held liable and subject to serious. financial'risk for any injuries sustained'by an unlicensed person and his or her employees while working on my Property. 'My homeowner's insurance may not provide coverage .for those injuries. I.am w'illMy acting as.an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers .'on my -property �2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are. nothiring a licensed Contractor. to.assume this responsibility. . I.uuiierstand as an "Owner -Builder" I am the responsitle'.party of record on the permit I understand that I..may protect .-. myself from potential financial risir by hiring a licensed Contractor and Having the permit filed in his' or her name instead of my own I uaderstand Contractors are required by law to be licensed and bonded in California and to list their license numbers on ermits and contracts. 9�5. I understand if i employ or otherwise engage any persons; other than California licensed Contractors, and the total value of my construction is at least five hundred dollars' ($500), including labor and materials, I may be considered an "employer" under state and federal law. I..understand if I am considered an "employer" under state and federal law, I must register with. the state and federal 'l government, . withhold payroll taxes, provide wo�kers`compefisation'disability insuranceand' contribute to uneiirploymentcgmpensatioh for each "employee:"falso undersmy failure: to abide by these laws may subject me to serious f nancial risk. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential .structures cannot .legally build them with the .intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four' within any calendar. year, .or all of the work is performed under. contract with a licensed general building Contractor. �8 I understated as an. Owner-13ader if I.sell the property for which this permit is -issued, I may be held. habte for any financial or personal. bouries sunt ed by any subsequent owners) that- result from any latent construction defects in the workmanship or materials. . I understated I may obtain more information regarding my obligations as an "employer" from the Interaai Revenue Service, the United States SmiallBusiness. Administration, the California Department ofMenefit Payments,-and.the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (C LI3. at 1- 800-321=CSLB (2752) or www.cslb.ca gov for more information about licensed c6mmetors. �i0. i am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the f ply legally and financially responsible .. for . proposed construction . activity at the following address: I 1. I agree. that,: as the Party legally and financially responsible 'for this proposed..coastruction activity,.1 will. abide by all .. .. applicable laws and rEgiureitents that govern awaer=Builders as -well as employers. 12.1 agree to notify the issuer of this. form immediately of any additions; deletions, o':chatges to any of the information I 10L2have provided on this form. Licensed contractors are .regulated by laws designed to protect the public. If you contract with someone who doesnot have a- license,. the Contractors' State License Board may be unable to assist'you with any financial loss . . you may sustain as a result of a complaint.. Your only remedy against unlicensed Contractors inay be-inl0vil court It is. also important for. you -to understand that -if air utllicensed.Contractor or employee of that- individual or firm is injured white working on your property; you may be held, Habit for -damages: If you obtain a permit as Owner -Builder and wish to Dire Contractors, . you will be .responsible for verifying .vfrether or not those Contractorsare propeAy-licensed and the st An of`their workers' compehsation•insu-mace coverage. Before a building permit can be issued, this form must be completed and signed- by the property owner and returned to the agency responsible fo'Jsst1ng,t #exmdt Note: A.copy, of flit property -owner's dxFv 'sl cense; form noterr-.i n,_ or other verification acceptable to the agony is.ri*** ed to be presented* wher4..dw peirnit is 4*0 to verify:the.propert3! owner's signature. Signature of property gwnef Date: ..Note.-, The following Authorization Form is required to be completed by the property owner only when- designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AMHORIZATION OF AGENT TO ACT ON PROPIERTY OWNER'S'BERA -Y F.xcluding.the Notice to Property Owner, .the execution of which I understand is my.personal respotrsibi4ty,,I hereby authorize the following persons} to act as my ageut(s) to:apply for, sign; and file*the documents necessary to obtain Ori Own(r-Builder . Permit for my project. . Scope of Construction Project (or. Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No - I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above informationi and certify its accuracy. Note: A copy of the owner's drivers license, form notarization,. or other verification acceptable to the agency is required`to bepresented'when, the permit is issued to verify the property owner's signature.. Property Owner's Signature: Date: Scope of work: Inspect previously installed gas line extension for code compliance and obtain completed permits. Residence 807691 Oak Tree La Quinta, CA 92253 CIN OF LA QUINTA ' BUILDING &SAFETY DEPT. APPROVED ATE 9 �ZIW SYR - J r4t; Bin # Qty of La Quinia Building 8i Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253: (760) 777-7012 Building Permit Application and Tracking Sheet Permit #\ �, LINA Project Address: J Owner's Name: , A. P. Number: Address: 8 ci- Legal Description: City, ST, Zip: G • -- 9 Z Z�3 Contractor: Address: Telephone: Project Description: _ City, ST, Zip: Telephone: }- .`.%l�l:i}}:+'i ::•Y•i:��fitii �'4i"r i1. ����<:>?••-.�-,.>:s:;;>..,:, t;<»<>::}:>;;:: State Lie. # : City Lie. Arch., Engr., Designer: Address: City, ST, Zip: Telephone: ':>':>` >:>''.>'<;::.>;: ''•:•':< 'v:>':`s :::<#::z:>:;=<;•:..;;•;:.,.:><:-<:• �����!�;•.::: i�'?'C}xf.>:fl::::3iii'+'::i+1.+i�.:E-iiiii.'•}F n4}y: Construction Type: Occupancy: State Lie. #: Project a circle one): New Add'n Alter Repair Dem J �'P i ) p o Name of Contact Person:Sq. FL: #Stories: # Units: Telephone # of Contact Person: Estimated Value of Project: 1191—' m APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Tide 24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2od Review, ready for correctionsfissue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- 'A Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees