BLCK (12-0180)54435 Avenida Madero
12-0180
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 1=12M00000180
Property Address:
54435' AVENIDA MADERO
APN:
774-231-008-8 -000000-
Application description:
WALL/FENCE
Property Zoning:
COVE RESIDENTIAL
Application valuation:
1450
T4hf 4 4 Q"
Applicant: Architect or Engineer:
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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 1 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
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_ 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
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.).
(y 1 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 1 I am exempt under Sec. , B.&P.C. for this reason
e: % Jiwner: _A_JY 24!;j
011
CONSTRUCTION LENDING CY
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:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/29/12
Owner:
DEBRA BIGGERSTAFF
54435 AVENIDA MADERO
LA QUINTA, CA '92253
------------------f ----- ------
Contractor:
!-1
Owner _
7 73 2012 f! !
----------------
--------------------------------------
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
I certify that, in the performance of the wbrk 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 sh uld become subject to the workers' compensation provisions of Section
;;pplicant: fth,Labor C Ia I forthv,( omply with those rovisions.
t
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COV E 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
of th' co ty o enter upon the above-mentioned prop e ar ' spectio poses.
Date: 7/ nature (Applicant or Agent):
Application Number . . . . . 12-00000180
Permit
WALL/FENCE PERMIT
Additional desc .
'Permit Fee . . .
. 35.00 Plan Check Fee
.00
Issue Date . . .
. Valuation . . .
. 1450
Expiration Date
8/27/12.
Qty Unit Charge Per
Extension
BASE FEE
15.00
10.00 2.0000
HND BLDG 501-2,000
:
20.00
-----------------------------------
Notes and
Comments
54 L.F. 6' GARDEN
WALL WITH 2 COLUMNS &
GATE, ORCO SYSTEM.
2010 CODES.
----------------------------------------------------------------------------
Other Fees . . .
. . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary
---------=-------
Charged Paid Credited
Due
Permit Fee Total
----------------------------------------
35.00 .00 .00
35.00
Plan Check Total
.00 .00 .00
.00
Other Fee Total
1.00 .00 .00
1.00
Grand Total
36.00 .00 .00
36.00
LQPERMIT
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
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FOR CONSTRUCTION I S T, 1 p G
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P.O. Box •1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner-Bullders Applying for Construction Permits`
[AIWORTIffTl N0' tG
Dear Property Owner.
'Ali. application for a building has been submitted in your name listing yourself as the builder of the property
improvements specified' at Q
We are providing you with an Owner -Builder A€Imowledgment'and Information Ver £Eation Foci to make you awam of your
reVensibilities and Possible risk -YOU may incur by having thispermit•issaed in your name as the
Owner -Builder. We will not issue a building permit until yoa•have read, initialed your understanding of eaeh`ptovlsion,
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-
ON
uthority.
OZ'S AeNON i Kb AN]) NEWWAXWN OF WO N
D&ECUONS: Bead and maiat ea h statement beth w signify you undnrsiand or ' this information.
2bL I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
ding permit that erroneously implies that the property owner is providing his or her own labor and material personaki. I, 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
mjunes. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance -coverage for injuries to workers
'on my property -
0— 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.
I understand as. an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
if from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
t4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
ernuts and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
my construction is at least five hundred dollars -($500), including labor and materials, I may be considered an "employer"
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
overnment, withhold payroll taxes, provide woikers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk,
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
tures 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 understand as an Owner -Builder if I sell the property for which this pernut is issued, I may be held liable for any
rnancial or personal_iio.aries sustained by any'subsequent owners) that result from any latent construction defects in the
workmanship or materials.
understand I may obtain more information regarding - my. obligations as an "employer" front the Internal .Revenue .
rvice, 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 (CSLB) at I-
800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
10. 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 f nancially responsible for. proposed construction activity at the following address:
agree that, as theparty legally and financially responsible for this proposed construction activity,.[ will abide by all
applicable laws and requirements that govern Owner -Builders as well aS employers.
12.1 agree to notify the issuer of this form immediately of any additions, deletions, or cho ages toany of the information I
ave provided on•this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
-someone who does not have a license, the Contractors' State License Board may be unable to assbO YOU with any financial loss
YOU may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be inleivil Count. It is- also
in)VOrtant for you to understand that if an unlicensed Contractor or employee of that individual or Brra is injured while worldag
on your property; You may be held Balk for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors,
you will be responsible for vaj*ing vðw or not those Contractors are property licensed, and the status of dwit Wottcers'
compensation insurance 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 issu€ 4 dw perm it. !Yore: A copy of Eire property owner's dk&WyOzertsa fame twiackadoth or
other verification acceptable to the agency is required to be presented when the permit is arsvte4 to verify the pivtperty
owner's signature. '
Signature of property owner 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.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWN'S BI ff F
Excluding. the Notice to Properly Owner, the execution of which I understand is my personal responsibility. I hereby authorize
the following person(s)• to act as my agents) to apply for, sign, and file the documents necessary to obtain ani owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work): /0 %OCJ V1/6LU
Project Location' or Address: , W3 _S7 A-V` 0
Name of authorized Agent:
Address of Authorized Agent:
Tel No
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 to be presented when the permit is issued to verify the property owner's signature..
Property Owner's Signature: Date:. o
ein.# City Of La. Quinta
Building 9 Sarety.Division ;
Permit # P.O. Box. 1504, 73-495 Calle Tampico
14.Quinta, CA 92253 - (760) 777-7012
- Building Permit AOplication and Tracking Sheet
FA.
ct Address: " — ' /.)<. V n,4:n Owner's Name:. D G G L ,
Number. Address:.51/- Al Description: City, ST, Zip:..
Contractor. Telephone: qU -Y 7 - yS
CY
Address: Project Description: i q L.1—
City,
1—
City, ST, Zip:
Telephone:
State Lie. #
Arch., Engr., Designer.
Address:
City, ST, Zip:
Telephone:
State Lie. #:
Name of Contact Person:
Telephone # of Contact Person:
City Lic. #. -4 1'6
`rM,
Construction T Occupancy:
t
r Type: / AJ
Project type (circle one): New . Add'n Alter Repair Demo
Sq. Ft.: # Stories: # Units:
o
Estimated Value of Project: Q '
APPLICANT: DO NOT WRITE BELOW THIS LINE
Req'd
Recd TRACICTPIG PERMIT FEES
FN
FSubmiftal
Plan Check submitted Item Amount
StructuraCalcs.
Reviewed, ready for corrections Plan Check Deposit. .
'Fuss Calcs.
Called Contact Person Plan Check Balance.
Title 24 Caics,
Plans picked up Construction
Mood plain plan
Plans resubmitted.. Mechanical
Grading plan
ra Review, ready for correctionsfssue Electrical
Subcontector List
Called Contact Person Plumbing
Grant Deed
Plans picked up S.M.L
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE:-
'"' Review, ready for correctionAssue Developer Impact Fee
Planning Approval.
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit Issue
School Fees
Total Permit Fees