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ELEC (12-1412)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 12-00001412 Property Address: 54210 AVENIDA MENDOZA APN: 774-223-010-13 -000000- Application description: ELECTRICAL Property Zoning: COVE RESIDENTIAL Application valuation: 2800 Ta�/ aF 4a 4" Applicant: Architect or Engineer: BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 ISec. 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 iequires 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 army!! applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•: 1 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and T 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 I am exempt under Sec. , BAP.C. for this reason /ate: 1--.1141 pwner: CONSTRUCTION LENDING AGENCY I hereby affirm under penal[ perjury that there is a construction lending agency -for the performance of the work for which IN Iris issued (Sec. 3,P27, Civ. C.). Lender's Name: Lender's Address: LQPERMIT Owner: TEDD HANKINS 54210 AVENID LA QUINTA, C ------------ Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 u ND 253 n CITY OF LA QUINTA FINANCE DEPT. Date: 12/06/12 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, Irthwith comply with those provisions. 'Date:f plicant: WARNING: FAIRE To WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS 1$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 o{this cou/n/tt/o/!enter upon the above-mentioned grope s coon pu pose - Date• � nature (Applicant or Agent): Application Number . . 12-00001412 Permit . . . ELEC-SERVICE CHANGE Additional desc . . Permit Fee . . . . 33.50 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 6/04/13 Qty Unit Charge Per - Extension BASE FEE 15.00 1.00 18.5000 EA ELEC SVC <=600V/<=200A 18.50 ---------------------------------------------------------------------------- Special Notes and Comments ELECTRIC PANEL CHANGE -OUT - 200 AMP. 2010 CODES. ----------------------------------------------------------- Other Fees . . . ----------------- . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited -------------------- Due ----------------- Permit Fee Total -------------------- 33.50 .00 .00 33.50 Plan Check Total .00 .00 •.00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 34.50 .00 .00 34.50 LQPERMIT r 4W P.O. BOX 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLS 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 .1 I�IUTIt:'R T[i punn�n.�, O�'YNFK . Uftr Property Owner. An. application for a building has srbulkled �i� at �_ Q 'your t>aaue listing yourself as the builder of the property We ars P'0VWiDg You With an Owner -Builder A0kD0 lWv neot and Inf xtuatwu Venfic6tm Form to make oath Yom-bave read, initialed your and vtaaYou aware of your and possible risk es -Builder. we � WaY incur by having thts pormi . mftd m your name as the will sot icaee a bulli "permit � of each pravisien, si4engned, and returned this form to us at our of1>dal address indicated. An agent of the owner carmot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. E}'S kC7tiIJ�TVI�I' �� �D � A'�IBN E>�T 1�Qll�ki'li�N DffdW fONS. Read and a,,*& e.dr starenresrrtamw- to si BinIY You ourdrtrararrd or ve#ythis ertfornaario+r. <J!�_Funderstand a frequent practice of unlicensed is to have ` building permit that enoneousl moons the property owner obtain an `Owner -Builder~' y implies that the Property owner is providing his or her own labor and material personalty. 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 sty property. l understand building permits are not required to be signed conre construction and anot hiring a Licensed Contractor to assume this by PAY owners unless they are responsible for the bilitY- 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. l understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on pernuts and contracts. WO- Tunderstand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value o my construction is at least five hundred dollars (5500) including labor and materials, I may be considered an "employer' under state and federal law. ' -:b" understand if I am considered an -employee' under state and federal law, I must register with the state and feden government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to uaemploymet compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financi risk. -49- T1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family resident structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licem subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perform under contract with a licensed general building Contractor. � t 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, paries sussed by any subsequent owner(s) that result from any latent construction defects. in the workmanship or materials. Vk4-1 understand I may obtain more information regarding my obligations as an "employu" from the lei Revenue Service, the United States Small Business Administration, the California Department of Beaefit Payments, and the California Division of Industrial Accidents. I also understand I troy contact the California Contractors' State License Baud (CBLB) at I - 800-321-CSLB (2752) or www.cslb.ra.gov for more information about licensed contractors. lr'�. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the Fes' legally and 54anciaHy responsible for proposed construction activity at the following address: ICZ Lfi I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applkable laws and requirements that govern Owner -Builders as well as employers. agree to notify the issuer of this form immediately of any additiom doldions, or c w*" to any of the iufvcmation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If YOU contract with somoar a who does not have a Hexose, the Contractors' State License Board may be unable to ash you with MY 6namial loss you may sustain as a result of a complaint Your only remedy agairut unlicensed Contractors may be is civil neem It is also impoctemt for you ter. understand that if an aniieoused Contractor oc eViloyee of that irrdivi&W or firm is iajared while working on your property; you may be ►cid liable for damages. If you obtain a permit as Owns -Builder and wig to hire CORUtCOM, you will be MWOUNIA0 for veering WhWM or " diose Contractors are property tkmsed and the status of their wavkus' conation insu neem ooverage. Before a building permit can be issued, this form must be completed and signed by the prop" owner and returned to the atency responsible for issue tm.permit, Nott: A copy of dw properV owsw's Miow!'h fWat noinkah'014 or other verification asetptaMi to the agency a required to be presented what Eke permit is iutsuul to xerlfp the property owner's signature. Signature1 property owner 'A/ ��/ �� 1. Note: 77re 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. AUFHORMATION OF AGENT TO ACT ON PROPERTY OWNER'SB �F Excluding the Notice to Property Owner, the txec3ution of which I understand, is my personal roWOM--bilitY. I hereby authonze die follow4 person(s) to act as my agent(s) to apply for, sign, and file the documents mcessary to obtain tic Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address - Name of �kuthoriaod Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the atm information and certify its accuracy. Nott: A copy of the owner's driver's license, form notarization, or other verification amwtable 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: a 1 understand as an Owner -Builder if 1 sell the property for which this permit is issued, I may be held liable for any financial or personal. itowies sustained by any subsequent owners) that result from any latent constivCdOn defects. in the workmanship or materials. A. I understand I may obtain more information regarding my obligations as an -employee' 6vm :ire latuall Rcvenue Service. the United States Small Business Administration, the California Department of Benefit Paymen'ds. and tbo California Division of Industrial Accidents. I also understand I Way contact the California Contractors' State License Board (ME) at 1- 800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 1 am aware of and consent to an Owner-Buildcr building permit applied for in my name, and understand that 1 am the party legally andcially responsible for proposed constivction activity at the following address: ,C� .._ . activ_ I agave that, as the ply wally and finaucially responsible for this proposed construction activity, l will abide by all apphcabk laws and rogtnirements that .govern Owner-Brrilders as well as employers. .12.1 agree to notify the issuer of this form immediately of any addition; doktivns, or cht+oges to *Oy of tlne infarnsation 1 have provided on this form. Licensed contractors are regulated by laws designed to protect the public- If you contract with som000e who door not have a liewim, the Contractors' State Liceme Board may be unable to asarat you with any 8nannal loss you may sustain as a result of a complaint Your only remody against unlicensed Contractors may be in civil oourt.'it is also impotlant for you to understand that if an m Aieensbd Contractor or employee of that in&vi&W or firm is injured while woring on your property; you may be hdd lulble for damage& if you obtain a permit as Ownff-BaiWer sad wi* to hue Coatradors, you war be responable for ve rdly ag why or not those Contractors arc papedy Iieensed and the status of their workers instuaam coverage,. Before a building permit can ¢e issued, this form must be completed and signed by the property owner and returned to the agency responsible for issrdag.tie permIL Note, A copy of dw pvpwV osrmer's &Ivw"i ftwaft fWW err► or other verification accq*Mc so the agency is K{uina to be praseated silken ike permit is immi so •may dne PrePeM owner's signature. Sigma= = of property owner Date / %Z- 110 - Note: Note: Ae following Authorization Form is required to be completed by the property owner orrly when designating an agent of the property owner to apply for a construction permit for the Owner-Builder- Facludi . the fol Permit t Scope c Project Nam c Addres I declar informs aciccpta Propert: I, hemby authoru an 6wv6t-Builder rzwo ally filled out the other vcrifrcation use's sign aturc- Bia # City of La Quinta Buiidiflg ei Safety Division Box 1504,78-495 Calle Tampico 14.Quinta, CA 92253 - (760) 777-7012 Building Permit 'Application and Tracking Sheet Permit # dV.P.O. 1� Project Address: r a.,(� � r Owner's Name:. �� u A. P. Number. Address: . 5 u e Legal Description: Contractor. City, ST, Zip: (%( Telephone: ,�,_ >z°?a Address: D eProject Description: City, ST, Zip: i '� �i Le �o4— Telephone -26,g ..-5�CC) City Lic. #; State Lic. # : Arch., Engr., Designer. Address: City., ST. Zip: Telephone: •Y '` ° '° State Lic. #: Construction Type:. Occupancy: Project type (circle one): New Add'n Alter Repair Demo Sq. Ft..#Stories: # Unity: Name of Contact Person: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS UNE # Submittal Rcq'd Rcc'd TRACKING PERMITFEES Plan Sets Plan Check submitted Item Amount Structural Cala. Reviewed, ready for corrections Plan Check Deposit. . Truss Calcs. Called Contact Person Plan Check Balance Tide 24 Calci. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan Review, ready for correctionstissue Electrical Subeontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- ''" Review, ready for corrections/issue Developer Impact Fee Planning Approval. Called Contact Person Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees r