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BLCK (09-1280)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 09-00001280 Property Address: 52120 AVENIDA MENDOZA APN: 773-233-006-17 -000000- Application description: WALL/FENCE Property Zoning: COVE RESIDENTIAL Application valuation: 888 Ta�v 4 XP Q" Applicant: Architect or Engineer: 041-e �k� ------------------ 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 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 a (pplicant 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 .01 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, 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.). I am exempt under Sec. _, B.&P.C. for this reason ,,,.�ate: I y I wne,: 0t&U'(1-Y K" 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: LQPERMIT Owner: SAMUEL DONLEY 52120 AVENIDA MENDOZA LA QUINTA, CA 92253 ---------------------------- VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 12/18/09 Contractor: Owner H 1 �82UO 0 9 1[ CITYOFf- - — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — WORKER'S COMPENSATION DECLARATION I hereby affirm unde * r penalty of perjury one of tha 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 VI c epr =a t. in the performance of the work for which this permit is issued, I shall not employ any n any manner so as to become subject to the workers' compensation laws of California, and agree that, it I should become subject to the workers' compensation provisions of Section 37 of the Labor Code��Il torth�ith corript",ith those provisions. 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 of this county er upon the above-mentioned property for inspection purpes!s�� te: If P(�W S�ig�ne lApplicant or Agent): CLA%,_j Application Number . . . . . 09-00001280 Permit . .. . . . . WALL/FENCE PERMIT Additional desc Permit Fee . . . . 23.00 Plan Check Fee .00 Issue Date Valuation . . . . 888 Expiration Date 6/16/10 Qty Unit Charge Per Extension BASE FEE 15.00 4.00 2.0000 HND BLDG 501-2,000 8.00 ----------------------------------------------------------------------------- Special Notes and Comments 41 L.F. 51 COURTYARD WALL WITH STUCCOED ARCHED GATE, CITY STANDARD. ---------------------------------------------------------------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged ---------- Paid Credited ---------- ---------- Due ----------------- Permit Fee Total ---------- 23.00 .00 .00 23.00 Plan Check Total .00 .00 .00 .00 Other Fee.Total 1.00 .00 .00 1.00 Grand Total 24.00 .00 .00 24.00 LQPERMIT A - . P.O. Box. 1504 LA Q(JINTA,' CALIFORNIA. 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-70 12 FAX (760) 777-7011 Disclosures & Forms'for Owner -Builders Appl�ring for Construction Permits 29-00-TANT! NOTICE TO PROPERTY OWNER Dear Property Owner Ari. application for a building has been s . mitted in your name listing yourself as the builder of theproperty e . -zw a ecified at improvements sp We are Providing You with an Owner -Builder Acknowledgment -and Information Verification Form to make you aware.of your responsibilities and possible riskyou may incur by having, this. permit issued in. your name as the Owner -Builder. We will not issue. a building permit until you have re ad, initiated your understanding of each-proviision, 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. ONN�WS ACKNOWLEDGMENT AND YEREFICATION OF MORMAMN DMECTfONS. Read and -initial each -statement below to signify you understand or verr;� this information. I understand a frequent ptactice of unlicensed pemns 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. 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 property- 1-- 2. 1 understand ' building permits are not required to'be signed by property owner's unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. L 3. 1 understand as an "Owner-Buildee' I am the re sponsible 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. P"'-4. I understand Contractors are required by law to be licensed and bonded in 'California . and to list their license numbers on permits and contracts. k'-5. 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 "employee' under state and federal law. k'-6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal goverrunent, withhold payroll taxes, prov * ide 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. I understand under Califomia 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. e--61 understand as an Owner -Builder if I.sell the property for which,th.is pert . rut is 'issued, I may be held liable for any financial or personal. injuries sWtained. by any subsequent owneF(s) that result from any latent construction defects in the worlananship or materials. �--�9- 1 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 t�e California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CS" LB) at I- 800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. I am aware of and consent to an. Own'er-Builder building permitapplied for in my name, and understand that I am the party legally and f-mancially responsible for proposed construction act e ivity at th following address: e-1 I U71 LA -1-1/11 Od 4!v:.�Z C A 145A A4 t:7�A IA­Z)_�Z 4 k'-1 1 .1 agree that, as the party legally and finaacially responsible for this proposed construction activity -I will abide by. all applicable liws and requirements that govern Owner-Auilders as well as employers. 2. 1, agree to notify the issuer of this form immediately of any additions deletions, or changes to any of the information I have 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 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 courL It is also important for you tauinderstand that -if an- , unlicensed Contractor or employee of that individual or firm is injured while worldng on your property; you may be held, liable 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 property licensed and the status of thelf 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 issuing, the permit Note: A copy of the-proper1jr owner's d4ver's,licensei 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. wrier Signatme of property o Date: 12-19- 0�? Note: Thefollowing Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to -applyfor a construction perinitfor the Owner -Builder'. � . AUTHORIZATION OF AGENT -TO ACT ONTROPERTY OWNEWS 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 4gent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Pem-iit for my project. A rapm Scope of Construction Project (or Description of Work): 07,Jen W T Project Location'or Address: S2_ 172 0 LoA:f)11', M0J'16_Z_7Ak LA Name of Authorized Agent: L TelNo -�-100-zyd_-Qo_i�— Address of Authorized Agent: I declare under penalty of perjury that 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 ofthe owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented whrff7hl p 't is issu d to verify the property owner's signature.. Property Owner's Signature: Date: 09 I F Ir *zQ NNI T INN 572 JAV I -A nj AWR CITY;10F LA OUINTA PT. BU 1,LDING, & S, AFETY D� APPROVED FOR CONS4TRU'CTION DATE/0? Bin # Qty of La Quinta -Building 8z Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Vacking Sheet' Permit # Project Address: jza Ale zVffAl Owner's Name : �5AIMUPJ Nn A. P. Number: Address: 52-1,20 fkve- YO rndhz-o� Legal Description: Contractor: City, ST, Zip: ...?4 a LAA r-7. Telephone 310 3 -95 1010 02 Address: Project Description: City, ST, Zip: (We,4 ay-orl-1) (t.113rW5,14 ee- Telephone: X* ........... :X-"--.1'........ State Lic. # City Lic. #.-. Arch., Engr., Designer: 0M 'LAJfT ArCO 67KIE �.Jfa %4* DrtiEr Address: 0 rvl WL City., ST, Zip: Telephone: State Lic. #: . ...... Construction Type: Occupancy: 'Project type (circle one): New Add'n Alter Repair Demo NJine of Contact Person: Sq. Ft.; # Stories: # Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE N Submittal Reqld Ree'd TRACKING PERMIT FEES - Plan Sets Plan Check submitted Item Amount' Structural Cales. Reviewed, ready for corrections Plan Check Deposit Truss CaIcs. Called Contact Person Plan Check Balant . e Title 24 Cales. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2" Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- 3rd Review, ready for correctionstrissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees