RER (12-1061)T-iht 4
P.O. BOX 1504 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 9/17/12
Application Number: 12-00001061 Owner:
Property Address: 51595 AVENIDA MENDOZA RESOLUTION FUND MANAGEMENT
APN: 773-142-017-5 -000000- C/O JOEL PEARCE
Application description: REMODEL - RESIDENTIAL 510 31ST, SUITE H
Property Zoning: COVE RESIDENTIAL NEWPORT BEACH, CA 92658
Application valuation: 400
Contractor:
Applicant: Architect or Engineer: Owner
. D
�� g 2012
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
1 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 ($500).:
(_ 1 1, 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 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
1/1 Date: 9 — 1 V_ 1 Z Owner: �_,_
CONSTRUCTION LENDING A9EN6T
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
WORKER'S COMPENSATION DECLARATION
iA E
1 hereby affirm under penalty of perjury one of the following d clarations'�+�"+'Y (�F LA QUINTA
_ I have and will maintain a certificate of consent t self -insure �r. eJs�oO� jSstion, as provided
for by Section 3700 of the Labor Code, for th or-wM'clt�}iis perm 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 o the rkers' compensation provisions of Section
3700 of the Labor Code, hal fo 9wi corn ith those provisions.
Date.. Applicant: I
WARNING: FAILURE TO SECURE WORKERS' COMPEN SATI N 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. 1 agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection ur ses.
Date:, Signature (Applicant or Agent): `
Application Number . . . . . 12-00001061
------ Structure Information ADD 5040 WINDOW AT GARAGE
-----
Other struct info . . . . . CODE EDITION
----------------------------------------------------------------------------
2010
Permit. . . BUILDING PERMIT
Additional desc . .
Permit Fee . . . . 15.00 Plan Check Fee
9.75
Issue Date . . . . Valuation . . .
. 400
Expiration Date . . 3/16/13
Qty Unit Charge Per
Extension
BASE FEE
15.00
----------------------------------------------------------------------------
Special Notes .and Comments
ADD 5o4o WINDOW AT SOUTH GARAGE WALL
[CONVENTIONAL] CODE CASE NO: 12-3015
[MR] 2010 CALIFORNIA BUILDING CODES.
September_'17, 2012 1:09:07 PM AORTEGA
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
ENERGY REVIEW FEE
.98
STRONG MOTION (SMI) - RES
.50
Fee summary Charged Paid Credited
---------------------------------------------------------
Due
Permit Fee Total 15.00 .00 .00
15.00
Plan Check Total 9.75 .00 .00
9.75
Other Fee Total 2.48 .00 .00
2.48
Grand Total 27.23 .00 .00
27.23
LQPERMIT
09/16/2012 23:26 9496733124 ROCKWEST PAGE 01
P_O. BOX 1504
LA. QUINTA; CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QVINTA, CALIFORNIA 92253
BUILDING Rc SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777,-7012
FAX (760) 777.7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
ft - ..I 1�(U7' CE 1�RQPERTY V WNE
Dear Property Owner:
Anapplication for a building permit has boen submitted in yourname listing yourself as the builder of the property
improvetrtents specified at t Av&zZhA MEN _ A Tbi ;YTC.A
reS r'm t�,n 3' with as Owner -Builder Actatvwledgment and In,fi�imatien Yerr"tivta Form to make you await of your
respoostbilities and possible risk you may incur by !raving this permit issued in your narlae as the
Oma -Builder. We will not issue a bud" permit until you have read, Initialed your understanding of each provision,
signed, and returned this form to us at our eMeW address indicated. An agent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
D 'S AC—ICKO 'L 'G T A Nn VV101VZCA N �F IlriiFOIL ATI
D't`Recnom. Read and irritial each statement below to signify you understand or verify this information,
�r 1_ I understand a frequent practice of Unticcmed persons is to have the property owner obtain an "Owner-Buildre'
building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as
an. Owncr-Builder, may be beld liable and subimt to serious financial risk for any injuries sustained by an unlicensed pe sou
and his or her employees while working on nay property, My homeowner's insurance may not provide coverage for those
injuries. I area willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my Property-
"*** 2, f under,Starad building permits are not required to be signed by property owners unless they are resporWhle for the
construction and are not hiring a licensed Coutraetor to assume this respoasibili.ty.
�+ 3. 1 understand as an "0vmer-Builder" I am the responsible patty of record on the permit. I understand that L may protect
myself from potential financial risk by hiring a licensed Contractor. and leaving the permit filed in his or her name instead of my
own.
"Ir 4. I understand Contractors are required by law to be liccttsed and bonded in California and to list their license numbers on
permits and contracts.
'*v_5. I understand if I employ or odaerwisc engage any persons, other than California licensed Contractors, and the total value
Of my construction is at leant five hundred dollars ($500), including labor and materials, 1 may be considered an "employer'
undcr state and federal law,
'I. 6. 1 understand if I am considered. an "employee' under state and federal. law, i must register with the state and fedcra
go arrt, withhold payrotl taxes, provide workers' compensation disability insurance, and contribute to unernploymen
compensation for each "etrtployec." i also understand 6y failure to abide by these laws may subject me to serious fmaneia
risk
�. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residenti:
strut ures cannot legally build them with the intent to offer therta for sale. unless all work is performed, by license
subs retractors and the number of structures does not exceed four within any calendar year, or all of the work is perforrac
under contract with a licensed general building Contractor.
09/16/2012 23:26 9496733124 ROCKWEST PAGE 02
�8. 1 understand as as Owner-Baildcr if f sell the property for which this permit is issued, 1 may be bold liable for any
fmancial or pal. ngjuritn mut$ined by any subsequent owne:r(s) that result from any Intent construction defects in the
wortJnanaNp or matmials.
�9. f understand I may obtain more information regarding my obligations as an "employer" from rbc lmrtnat Revenue
Service, the, United States Small Business Administration, the Calirprnia Department of Benefet Payments, acrd the E;aI&Mia
Division of Industrial Accidents- I also understand i may contact the CAlifornia Contractors' State License Board (CSLR) at I-
800-3?.1-C'SLB (2752) or www.csib.ca.gov for marc informatitm about licensed contractors-
10. law aware of acrd consent to an Owner -guilder building permit applied for in my name, and understated that 1 am the
Party legally and financially rewoosible for proposed consttuetioa activity at the following addmm;
11_ [ agree that, as the Party legally and financially responsible. for this proposed construction activity,[ will abide by all
applicable laws and requirements that. govern Owner -Builders as well as cmployc s,
Ns'%► 12. t agree to notify the issuer of this form immediately of any additions, deletions, of chi to stay of the information I
have provided on this forth- Licensed contractors arc regulated by laws designed to protect the public. ff you contract with
someone who dost not have a hoe nse, the Contractors' Stale Liceosc Board may be unable to assist you with my (ina mW loss
you may rascals as a result of a complaint Your only, remedy against unlictmAd Cop.Uactors may be is civil coerrt, It is also
impotte A for you ta: uttdastand that if An trralicatts6d Cunt motor cc emiluloyee of than trtdividnal or finer is injured widk working
on your property; you may be )weld tiabla for damages, if you obtain a permit as Owner-Baildet and with to hire Coaantelors,
you wdl be msponsibla for vaij),igg _i?Wm or nM those Co nraetors aro
mon itssereauoc covmvtt. PAY liamneed and rite status of their workers'
Belorc a building permdt can be issued, this form atust be completed and sii nen by the prop" owner aced retwtned to
the regency respovAble for Ist oft the pc runt Not -' A copy of the property owner's dki er's Abartseg forms r (4FAMd y or
older vuifrcadon aeaTsw fe $o rhe 0rtey is reae ukwd to be prwerued rohen the perrnft is 4"aed so verify the pr'apcM
owner's signature.
MAn1+��sR$1'L►
SignaRutr of Property oeerner ��•p�--�� Date:
RcSolvi_ion) acvA;b fKAWAGErn647 c.Le-
Note: The following Authorization Form is required to he completed by the property owner• only when designating
an agent of the property owner to apply for a construction permit for the (honer -Budder.
AU RORMALTION.OF AGENT TO ACT ON PROPERTY OWNER'S BFA!AbF
Fatcluding the Notice to Property Owner, the execution of which 1 understand is my personal responsihihty, t hemby autborim
the following PCM*) to act as. my agent(s) to alrlely for, sign, and file the dncmmcnts necessary to obtain an Owner•BuAder
Permit for my project.
Scope of Construction Project (or Dcscripdon of Work)- _ZM Spot G ; 2.kV _a�j�
Pmject Location or Addmss:
Name of,Authorized Agent: )jr, Tel No 1-7
ol�" ! l"7
Address of Authorized Agerrt:
I declare under perxa.lty of perjury. that I ant the property owner for the address I icted above arid, I personally Filled out the above
information and certify its accuracy, Note_ A copy of the owner's diver's license, form notarization, or other verification
acceptable to the agency is required to be pmvimted when, the permit is issued to verify the property owner's xigaature. i
Property Owner's Sigwturz �,�„��` (1fy�q ASL Date q—) O�_tZ
of i �A124--
REsowa cry ruNl> MANAGEmErv-r- Ltc
09/16/2012 23:26 9496733124 ROCKWEST PAGE 04
09/16/2012 23:26 9496733124 ROCKWEST PAGE 03
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City of La Qui'nta
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Permit H
P-0. Dox 1504,78.495 Calle Tampko
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La.Qu1t'tia, CA 91253 - (760) 777-7012
8Elilding Permit APP11cadon'and Tracking Sheet
Prv)eat Address: 515 9 S A wkMA M
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Name of Contact Petson
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Telephone � of Contad Parson:
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APPLICANT, DO NOT WRITE BELOW THIS LINE
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