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BLCK (12-0733)44865 Los Manos Dr 12-0733 P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Applicant: Architect or Engineer: • " BUILDING & SAFETY DEPARTMENT BUILDING PERMIT LICENSED CONTRACTOR'S 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 Class: License No.: Date: Contractor: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by an applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: 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 Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within 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.). (_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). (_ ) 1 am exempt under Sec. , B.&P.C. for this reason /0-tel:Z / carter: CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: Lender's Address: Ipt LQPERMIT Owner: KEITH BRUNER 44865 LOS MANOS DRIVE LA QUINTA, CA 92253 Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 7/02/12 WORKER'S 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 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 and policy number are: Carrier Policy Number 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 370Vft,,c Labor Code, I shall forthwith comply with those provisions. 7— D te: r ant: 4_1X1919 A'X//i c. Olt WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 a result of this application, 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. 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 county ordinances and state laws relating to building construction, and hereby authorize representatives oft'county to enter upon the bove-mentioned property fo inspecti purpo Signa re (Applicant or Agent): Ya Application Number:12-000007331'' Property Address: 44865 LOS—MANOS DR APN: 604-272-008-116 -23913 - Application description: WALL/FENCE Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 300 Applicant: Architect or Engineer: • " BUILDING & SAFETY DEPARTMENT BUILDING PERMIT LICENSED CONTRACTOR'S 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 Class: License No.: Date: Contractor: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by an applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: 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 Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within 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.). (_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). (_ ) 1 am exempt under Sec. , B.&P.C. for this reason /0-tel:Z / carter: CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: Lender's Address: Ipt LQPERMIT Owner: KEITH BRUNER 44865 LOS MANOS DRIVE LA QUINTA, CA 92253 Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 7/02/12 WORKER'S 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 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 and policy number are: Carrier Policy Number 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 370Vft,,c Labor Code, I shall forthwith comply with those provisions. 7— D te: r ant: 4_1X1919 A'X//i c. Olt WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 a result of this application, 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. 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 county ordinances and state laws relating to building construction, and hereby authorize representatives oft'county to enter upon the bove-mentioned property fo inspecti purpo Signa re (Applicant or Agent): Ya Application Number . . . . . 12-00000733 Permit . . . WALL/FENCE PERMIT Additional desc . . Permit Fee . . . . 15.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 300 Expiration Date . . 12/29/12 Qty Unit Charge Per Extension BASE FEE 15.00 ---------------------------------------------------------------------------- Special Notes and Comments ADD _ 12 L.F. 6' GARDEN WALL TO EXISTING WALL, CITY STANDARD, PER PLANNING APPROVAL (JW). 2010 CODES. -----------------7---------------------------------------------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited Due ----------------- ---------- ----------- ---------- ---------- Permit Fee Total 15.00 .00 .00 15.00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 16.00 .00 .00 16.00 LQPERMIT 9:1) %19 ST - 9 e wo® a / 1 P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OVMER'S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permitil MUNT1 IKQT>E 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 at We are Pmvid ag you with an Owner -Builder Aelmowleagment aad. Information VerifiEation Forms to make you awam of your eeVensibilities and possible risk -you may incur by having thispermitismad in your name as the Owns -Builder. We will not Ism a building permit until ym*ave read, initialed your undcrstaading of ea&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. 0 "s.fie L➢G 'r WA'Flidltt OF URVOMATWN Dr:head a mrtial eat statwnent be&wlb signify you ura&rstnnd or ver• yy this &Orm hon. . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Buddee, building permit that erroneously implies that the property owner is providing his or her own labor and material personally ji. 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 willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my Party. )%2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. -t`-a- " I understand as. an "Owner -Builder" I am the responsible.party of record on the permit I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. a4.I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on : and contracts. &5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value f my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employee" under state and federal law. &6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and I contribute to unemployment compensation for each "employee." I also understand my faihre to abide by these laws may subject me to serious financial risk -4--i' 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. s 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any ancial or personal. bouries sustained by any subsequent owner(s) that result from any latent construction defects in the worlonanship or materials. &9. 1 understand I may obtain more information regarding my obligations as an "employee" from the Interpal F-Ownue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSI. at 1- 800-321-CSLB (2752) or www.cstb.ca.gov for more information about licensed contractors. 0. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and fnanciatly responsible for proposed construction activity at the following address: 1. I agree that, as the party legally and financially responsible for this proposed construction activity, .I will abide by all app icaI46 laws and requirements that govern Owner-Budders as well as employes. 2. I agree to notify the issuer of this form immediately of any additions, deletions, or chaffs to any of the information I have provided on this form Licensed contractors are regulated by laws designed to. protect the public. U you eontract with someone who does not have a license, the Contractors' State License Beraud inay be tenable to assist you with any finaneial loss you may sustain as a result of a complaint Your only remedy against unlicensed Contractors may be in'aivd court. It is- also ihiportant for you to undershmd tMt-if an unlicensed.Contractor of employee of that individual or firm is inimed while working on your Property; You may be held H" Por damages. If you obtain a permit as Owner -Builder and wish to him Contaaetors, you will be responsrblo for ver&ying v&etim as not those Coutmotom are properly licensed and the staters of their weAers' cordon instrran©e 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 for isarsittg t#m<pxs€mlf.lVote: A copy, of dregropertyownor's dWver!s ssy or+tc+oeta rrr or other verification acceptable to the agency is req.uh ad to be presented when the p,?.arnit is issued to ver* the property owner's signature. Signature of property owner Date - Note: Note: The following Authorization Forret 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. AUTRORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BF F Excluding.the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following persons} to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: ) S ILD 4 L-4 0 o/ Name of authorized Agent: I{' % l L Va- •eZ Tel NoAddress of Authorized Agent: 4 r tI Q I declare under penalty of perjurythat I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is requir d b 'ted when the permit is issued to verify the property owner's signage.. to resen Property Owner's Signature: Date: 2, # oty. Of LQ Quin- to Bul*g &- Safety Division Box 1504,'78-49S Calle TarnplCD La Writa, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit #P.O. 3b J a Project,Add=.: 4 g(OS LDS man os. D r Owner's Name:. A. P. Number.. Address: Hy &S Lus YVlctnus, Or - Legal Description: Contractor. City, ST, Zip: LA— Qlti h - "l a'd s 3 Telephone: "i,4ti,e',, 91k a s Address: Project Descnption: — C) u_+ City. ST, Zip: _-For ki le GO Telephone: :, 1 Cori(e c_ State Lie. # : City Lic. M. Arch., Engr., Designer uyi vnt rs 4-o Acle -5s Address: }/ / f " /(1 xi L` — City., ST, Zip: Telephone: State Lie. #: • '~` v Name of Contact Person: Construction Type: iii WOc, panty: Project type (circle one): New Add' Alter Repair Demo Sq. FL: # Sttoori'*es #Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACMG PERMIT FEES - Plan Sets Pian Cheek submitted Item Amount Structural Coles Reviewed, ready for corrections Plan Check Deposit, . Truss Cales• Called Contact Person Pian Check Balance Title 24 Cates, Plans picked up Construction Flood plain plan Plans resubmitted •' . Mechanical Grading plan 2`! Review, ready for correctiouetssue . Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up SALL H.O.A. Approval Plans resubmitted Grading IN HOUSE:- 1n° Review; ready for correctionsAssue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub: Wks. Appr Date of permit issue School Fees Total Permit Fees