BELC2014-104078-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property' Address:
APN: I
Application Description:
Property Zoning:
Application Valuation:
Applicant:
ROWLAND GOMEZ
45544 KING ST.
INDIO, CA 92201
COMMONITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
BELC2014-1040
52519 AVENIDA MENDOZA
773302013
UPGRADE SERIVCE TO 200 AMP AND RELOCATE
$800.00
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
SHARON HURWITZ
300 ARROYO SALADO
SANTA FE, NM 92253
Contractor:
OWNER/BUILDER
LIc. No.:
Date: 10/31/2014
LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 1 hereby affirm under penalty of perjury one of the following declarations
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and
_ I have and will maintain a certificate of consent to self -insure for workers'
my License is in full force and effect.
compensation, as provided for by Section 3700 of the Labor Code, for the performance of
License Class: _ License No.: _
the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Date: Contractor:
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:
OWNER -BUILDER DECLAATI
Carrier: _ Policy Number: _
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
_ I certify that in the performance of the work for which this permit is issued, I
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
shall not employ any person in any manner so as to become subject to the workers'
city or county that requires a permit to construct, alter, improve, demolish, or repair any
compensation laws of California, and agree that, if I should become subject to the
structure, prior to its issuance, also requires the applicant for the permit to file a signed
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
statement that he or she is licensed pursuant to the provisions of the Contractor's State
comply with those provisions.
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
Date: Applicant:
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).:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
I ' ) I, as owner of the property, or my employees with wages as their sole
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
compensation, will do the work, and the structure is not intended or offered for sale.
HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does not
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
apply to an owner of property who builds or improves thereon, and who does the work
INTEREST, AND ATTORNEY'S FEES.
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
APPLICANT ACKNOWLEDGEMENT
within one year of completion, the owner -builder will have the burden of proving that he
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
or she did not build or improve for the purpose of sale.).
the conditions and restrictions set forth on this application.
I )'I, as owner of the property, am exclusively contracting with licensed contractors to
1. Each person upon whose behalf this application is made, each person at whose
construct the project. (Sec. 7044, Business and Professions Code: The Contractors' State
request and for whose benefit work is performed under or pursuant to any permit issued
License Law does not apply to an owner of property who builds or improves thereon, and
as a result of this application, the owner, and the applicant,' each agrees to, and shall
who contracts for the projects with a contractor(s) licensed pursuant to the Contractors'
defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
State License Law.).
employees for any act or omission related to the work being performed under or
(� I am exempt under Sec. B.&P.C. for this reason
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
Date: Owner:
for 180 days will subject permit to cancellation.
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 Na
Lender's Address:
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-
mentioned property for inspection purposes.
Date: Signature (Applicant or Agent):
DESCRIPTION
FINANCIAL INFORMATION
ACCOUNT QTY AMOUNT PAID PAID DATE
BSAS SB1473 FEE
101-0000-20306 0 $1.00
$1.00 10/31/14
PAID BY
METHOD RECEIPT #
CHECK #. CLTD BY
ROWLAND GOMEZ
CHECK R2624
232 AZA
Total Paid forBUILDING STANDARDS ADMINISTRATION BSA $1.00. $1.00
DESCRIPTION•
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
SERVICES
101-0000-42403
0
$24.17
$24.17
10/31/14
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
ROWLAND GOMEZ
CHECK
R2624
232
AZA
DESCRIPTION
ACCOUNT'
QTY
AMOUNT
PAID
PAID DATE
SERVICES PC
101-0000-42403
0
$12.09
$12.09
10/31/14
PAID BY
METHOD
RECEIPT-#
CHECK #
CLTD BY
ROWLAND GOMEZ
CHECK.
R2624
232
AZA
Total Paid for ELECTRICAL: $36.26 $36.26
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
10/31/14
PAID BY
METHOD
RECEIPT #
CHECK # .
CLTD BY
ROWLAND GOMEZ
CHECK
R2624
232
AZA
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
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 -Builders Applying for Construction Permits
IMPORTANTL_NOTICE TO PROPERTY OWNER
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 52519 Avenida Mendoza, La Quinta, CA 92253
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 in your name as the
Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each 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.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS. Read and initial each statement below to signify you understand or verify this information.
X 1. 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.
X 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.
X 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.
X 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.
X 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 "employer"
under state and federal law.
X 6. 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.
X 7. 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.
X 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
X 9. 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-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
X 10. 1 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 construction activity at the following address:
52519 Avenida Mendoza, La Gluinta, CA 92253
X 11. 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.
X 12. I 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 court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working
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 properly licensed and the status of their 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 property 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.
Signature of property owner J4040% E4 b h at 14AW61
6
Date 10 — 31 — 2014
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 pennit 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): Upgrade Electrical service to 100 Amp
Project Location or Address: 52519 Avenida Mendoza, La Quinta, CA 92253
Name of Authorized Agent: Roland Gomez
Address of Authorized Agent: 45544 King Street, Indio, CA 92201
Te1No 760-574-9048
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 of the owner's driver's license, form notarization, or other verification
acceptable to the agency is required to be presented when the pennit is issued to verify the property owner's signature.
Property Owner's Signature: ,SJ411°L Cf`^44
Date: 10 — 31 — 2014
e
Um
M -z, =E-
t
DRIVER'$ LICENSE
License # 032612946 ISSUED 03/1 F'
Date of Birth 09/26/1963 EXPIRES 10
HURWITZ
SHARON R
o
300 ARROYO SALADO
J,
SANTA FE, NM 87508
EIGHT 5'0
SEX .F
WEIGHS
135--..EYES--GRN
-6RN
7—
�ZNTS
RESTRICTIONS IONS N
DOMORQ '
Description: UPGRADE SERIVCE TO 200 AMP AND RELOCATE
STAFF NAME
ADDITIONAL
CHRONOLOGY
ACTION DATE
Type: ELECTRICAL Subtype:
Status: APPROVED
Applied: 10/30/2014 SKH
Approved: 10/30/2014 SKH
Parcel No: 773302013 Site Address: 52519 AVENIDA MENDOZALA QUINTA,CA 92253 _
Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 107
Lot: 1
Issued:
UNIT 11
CONDITIONS
Lot Sq Ft: 0 Building Sq Ft: 0
Zoning:
Finaled:
Valuation: $800.00 Occupancy Type:
Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0
No. Unites: 0
Details: ELECTRICAL -INCREASE ELECTRICAL PANEL TO 100 AMP AND RELOCATE. 2013 CALIFORNIA BUILDING CODES.
CHRONOLOGY TYPE
STAFF NAME
ADDITIONAL
CHRONOLOGY
ACTION DATE
COMPLETION DATE
NOTES
PLAN CHECK SUBMITTAL
RECEIVED
STEPHANIE KHATAMI
10/30/2014
10/30/2014
APPROVED BY JIM JOHNSON, STILL NEED OWNER BUILDER
FORM. (SK)
CONDITIONS
NAME TYPE
NAME
ADDRESS1
b
CITY STATE
ZIP
PHONE FAX EMAIL
APPLICANT
ROWLAND GOMEZ
45544 KING ST.
INDIO CA
92201
(505)603-6364
CONTRACTOR
OWNER/BUILDER
(505)603-6364
OWNER
SHARON HURWITZ
300 ARROYO SALADO
SANTA FE NM
92253
(505)603-6364
FINANCIAL INFORMATION
Printed: Friday, October 31, 2014 4:27:30 PM 1 of 2
�.
Permit Details PERMIT NUMBER 3
City of La Quinta BELC-2K'4-1040
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
RECEIPT #
CHECK #
METHOD
PAID BY
CLTD
BY
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
10/31/14
R2624
232
CHECK
ROWLAND GOMEZ
AZA
Total Paid for BUILDING STANDARDS ADMINISTRATION $1.00 $1.00
BSA:
SERVICES
101-0000-42403
0
$24.17
$24.17
10/31/14
R2624
232
CHECK
ROWLAND GOM97
AZA
SERVICES PC
101-0000-42403
0
$12.09
$12.09
10/31/14
R2624
232
CHECK
ROWLAND GOMEZ
AZA
Total Paid for ELECTRICAL: $36.26 $36.26
PERMIT ISSUANCE
101-0000-42404
1 0
$91.85
$91.85
10/31/14
R2624
232
CHECK I
ROWLAND GOMEZ
AZA
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
TOTALS: $129.11 $129.11
INSPECTIoNs
SEQID ..INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED
DATE DATE
RESULT REMARKS NOTES
ELECTRICAL FINAL"
BOND INFORMATION.
ATTACHMENTS
Printed: Friday, October 31, 2014 4:27:30 PM 2 of 2 tr-1 _