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BPLB2016-011978-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 T-iht 4 4& Qabts DESIGN & DEVELOPMENT DEPARTMENT VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions 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 any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 1(S 0).: 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 she did not build or improve for the purpose of sale.). 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 pursua to jntractors' State License Law.). Q►V,amexempt under Sec. . B.&P.C. for this reason Date: C O �Y Owner:/ "� CONSTRUCTIOI 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 Lender's Llc. No.: Date: 10/6/2016 WORKER'S COMPENSATION DECLARATION I hb 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 ?rk 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: Car • Policy Number: _ 1 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 t the workers' compensation provisions of Section 3700 of the Labor Code, I sha ort ith comply with /hose rrovisions. Date: Y �f� Applican . 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 Building Official 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. ny permit issued as a result of this application becomes null and void if work is commenced within 180 days from date of issuance of such permit, or cessation of rk 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 this city to enter upon the above -menti edpr erty for inspection purposes. Date. Signature (Applicant or Agent): BUILDING PERMIT _ Application Number: BPLB2016-0119 Owner: '1110 Property Address: 51540 AVE NIDA MENDOZA 1� p z HERNANDEZ APN: 773143003 oCT O rAf51540AVENIDAMENDOZA Application Description: HERNANDEZ RESIDENCE / SEWER HOOK UP� —_ 2���� QUINTA, CA 92253 Property Zoning: p' 9 Application Valuation: $100.00 Applicant: Contractor: MARIO HERNANDEZ OWNER / BUILDER 51540 AVENIDA MENDOZA LA QUINTA, CA 92253 LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions 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 any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 1(S 0).: 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 she did not build or improve for the purpose of sale.). 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 pursua to jntractors' State License Law.). Q►V,amexempt under Sec. . B.&P.C. for this reason Date: C O �Y Owner:/ "� CONSTRUCTIOI 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 Lender's Llc. No.: Date: 10/6/2016 WORKER'S COMPENSATION DECLARATION I hb 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 ?rk 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: Car • Policy Number: _ 1 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 t the workers' compensation provisions of Section 3700 of the Labor Code, I sha ort ith comply with /hose rrovisions. Date: Y �f� Applican . 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 Building Official 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. ny permit issued as a result of this application becomes null and void if work is commenced within 180 days from date of issuance of such permit, or cessation of rk 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 this city to enter upon the above -menti edpr erty for inspection purposes. Date. Signature (Applicant or Agent): Application Number: BPLB2016-0119 Property Address: 51540 AVENIDA MENDOZA APN: 773143003 Application Description: HERNANDEZ RESIDENCE / SEWER HOOK UP Property Zoning: Application Valuation: $100.00 Applicant: MARIO HERNANDEZ 51540 AVENIDA MENDOZA LA QUINTA, CA 92253 Detail: CONNECTING TO SEWER LATERAL. PER 2013 CALIFORNIA BUILDING CODE. Owner: MARIO HERNANDEZ 51540 AVENIDA MENDOZA LA QUINTA, CA 92253 Contractor: OWNER / BUILDER Llc. No.: Date: 10/6/2016 FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT QTY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $96.27 Total Paid for PERMIT ISSUANCE: $96.27 DESCRIPTION ACCOUNT QTY AMOUNT BUILDING SEWER 101-0000-42401 0 $12.67 DESCRIPTION ACCOUNT QTY AMOUNT BUILDING SEWER PC 101-0000-42600 0 $12.67 Total Paid for PLUMBING FEES: $25.34 Qin 1't , r �I Permit �; `��1 I n h vv 6 Project Address: City of La Quin to Buifding 9 Safety Division 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7011 Building Permit Application and Tracking Sheet A. P. Number: Address: �57/— 5Ve 4`6/%D4 Legal Description: City, ST, Zip: 01An* t� cf 22- J Contractor: � Telephone: >�y 2 one: Address: 51-5.�40//� Project Description: City- ST, Zip: Telephone: 7 SZ� o 2V) aIn State Lie. # : City Lie. #: Arch., Engr., Designer: Address: City, ST, Zip: Telephone: one: Con tructi n Type: , State#. Lie. ic. • a (circle ne • New Add'nProJect tyP Alter Repair. Demo 0 Name of Contact Person: Sq. Ft.: #Stories:nn #Units: Telephone # of Contact Person: Estimated Value of Project: V ` APPLICANT: DO NOT WRITE BELOW THIS LINE it Submittal Req'd Rcc'd TRACKING . PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Cafes. Reviewed, ready for corrections Plan Check Deposit Truss CaIcs. Called Contact Person Plan Check Balance Title 24 Cafes. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2°" Review, ready for corrections/issue Electrical SubcontacCor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval flans resubmitted Grading JN HOUSE:- '`'. Review, ready for correctionstissuc Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees, Total Permit Fecs M COACHELLA VALLEY WATER DISTRICT P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651 INVOICE Date: 10/5/2016 SUBJECT: SANTA CARMELITA, 51540 AVENIDA MENDOZA, LA QUINTA, LID 681782, "SCC FEE ONLY" MARIO M. HERNANDEZ Project: 16-7500 PO BOX 713 Project Date: 10/5/2016 Amount Due: $4,851.00 LA QUINTA, CA 92247 GEO: 06-06-01-4 Planner: SANDRA VILLALOBOS 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 $2,436.00 1 $2,436.001 $4,851.00 PAID $ Development Services Department OCT 6 2016 Coachella Valley Water District 75-515 Hovley Lane East Palm Desert, CA 92211 ' SUBJECT: SANTA CARMELITA, 51540 AVENIDA MENDOZA, LA QUINTA, LID 681782, "SCC FEE ONLY" COACHELLA VALLEY WATER DISTRICT P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651 Page 1