PLBG (13-1143)51802 Avenida Martinez
13-1143
TWif 4
P.O. BOX 1504 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT 11YSPECTIONS (760) 777-7153
BUILDING PERMIT 0O
Date: 9/10/13
Application Number: 13-00001143 Owner:
Property Address: 51802 AVENIDA MARTINEZ ERICA CHASE-WESSLEN
APN: 773-181-025-22 -000000- P.O. BOX 2001
Application description: PLUMBING LA QUINTA, CA 92247 <A Q
Property Zoning: COVE RESIDENTIAL (760) 777-1946 C iy 1
Application valuation: 1500 O
W
Contractor: 4 c`cQ Cij O, D
Applicant: Architect or Engineer: Owner
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
Licens aw (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he r she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
e° pl cant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
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.).
1 ISIPMV 7
as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
ss and Professions Code: The Contractors' State License Law does not apply to an owner of
builds or improves thereon, La.
d who racts for the projects with a contractor(s) licensed
he Contractors' State Licenseer Sec. &P.C. fs reason
-Date: Owner: ,O
CONSTRUCTION DING 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.I.
Lender's Name:
Lender's Address:
LQPERMIT
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 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, I shall forthwith comply with those provisions.
Date: Applicant:
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 etbove ' o 'n is corr t. o comply withall
city and county ordinances and state laws relating uction, a her auth 'z r sentativesof this c my o enter upon the above-mentioned ction purp
Date: vSignature (Applicant or Agent
Application Number . . . . . 13-00001143
Permit . . . PLUMBING 2013
Additional desc .
Permit Fee . . . . 11.92
Plan Check Fee
.00
Issue Date . . . .
Valuation . . .
. 0
Expiration Date 3/09/14
Qty Unit Charge Per
Extension
1.00 11.9200 EA PLBG BUILDING SEWER
11.92
----------------------------------------------------------------------------
Special Notes and Comments
SEPTIC ABANDON, SEWER CONNECT. 2010
CALIFORNIA BUILDING CODES.
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG
STDS ADMIN (SB1473)
1.00
PERMIT ISSUANCE M/P/E
90.57
PLAN
CHECK, PLUMBING
11.92
Fee summary Charged Paid Credited
---------------------------------------------------------
Due
Permit Fee Total 11.92
.00 .00
11.92
Plan Check Total .00
.00 .00
.00
Other Fee Total 103.49
.00 .00
103.49
Grand Total 115.41
.00 .00
115.41
LQPERMIT
A`T COACHELLA VALLEY WATER DISTRICT
p7sr rt P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651
i INVOICE Date: 8/8/2013
SUBJECT: SCC ONLY- 51802 AVENIDA MARTINEZ, LA QUINTA, LID 682622
ERICA WESLEN . Project: 13-4764
51802 AVENIDA MARTINEZ Project Date: 8/8/2013
Amount Due: $4,851.00
LA QUINTA, CA 92253 GEO: 6-06-01-4
Planner: - -SARA LOPEZ
TO INSURE PROPER CREDIT, PLEASE RETURN THIS PORTION WITH
REMITTANCE AND INCLUDE THE PROJECT ON YOUR CHECK
1.00 FF SCC -COLLECTION $2,415.001 $2,415.00
1.00 FJ SCC -TREATMENT $2,436.001$2,436.00
$4,851.00
$ P'J! 0
7
AUG -:8 2013
COACHELLA VALLEY
WATER DISTRICT
SUBJECT: SCC ONLY- 51802 AVENIDA MARTINEZ, LA QUINTA, LID 682622
COACHELLA VALLEY WATER DISTRICT
P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651
Pagel
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
7$-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY O MER' S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
LAW,QATANT! NOTICE TO PROPIERITY.OWNIER
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 -pj - ;0 Z n v e -p i da
We are providing you with an Owner -Builder Acknowledgment and Information -Verification -Form. to make you aware:of your
responsibilities and possible risk you may incur by having this -permit issued mi your name as the
Owner -Builder. We will not issue a building -permit until yowhave rend, initialed your understanding of earch`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.
Read and initial each statement below to* signify you uiaderstand or verify this information.
I1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 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
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. -Property.
understand building permits are not required to be signed by property owners unless they are responsible for the
ion and are not hiring a licensed Contractor to assume this responsibility..
CI 3 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.
I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
pe and contracts.
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 tate and federal law.
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 contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
1 Jo 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.
I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be he'd liable. for any
financial or personal. injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
WorRInanship or materials.
LW9- I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
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 (CSLB) at 1-
800- 1-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 financially responsible . for proposed constructio activity at the f llowing address:
c
1-A02: ONllkda 1'YIQrl tl e - L4 0140A...00 53
I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
4,agree to notify the issuer of this form immediately of any additions, deletions, or changes to any 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,. Hie 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 may be in civil court. It is also
important for you tounderstand that if an unlicensed Contractor or employee of that individual or firm is intured while working
on your property; you may be heldliable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors,
you will be .responsible for verifying whether or not those Contractors are properly licensed and the status of dwir workers'
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 issaiug,&e..pef ote: A copy of tke property owner's driver'sJkensri farm "k*661wa; or
other verifkation acceptable to the agen is aired presented when die permit is i9F1W to verifY the PfOoPeM
owner's signature.
Signature of property owner Date: / b L—S
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 OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand. is my personal responsibility, I hereby authorize
-the following person(s) 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:
Name of (authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that 1 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 required to be presented when the permit is issued to verify the property owner's signature.
Property Owner's Signature: Date: