BLCK (10-0422)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011'
INSPECTIONS (760) 777-7153
Date: 5/13/10
- -
Application Number: 10-b0000422 `.
Owner:
Property Address: 79808 MORRIS AVE
OLSON CHRIS & f
ZABE
APN: 604-511-003-10
-24197 -
79808 MORRIS
Application description: WALL/FENCE
LA QUINTA, CAS
253 L'
Property Zoning: LOW DENSITY RESIDENTIAL
(760) 636-1944
F;� /
Application valuation: 400
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1 42010 (((�
tor:..
`E�II`•
Applicant:
Architect or Engineer.
Owner •
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 (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 oy.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).:
( ✓�) 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 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 Contiactors'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 rea n
(Dater Owner:
CO UCTION 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
------------------
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'cenify 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 suNect to the workers' compensation -p ions of Section
fy1 �� /37700of the Labor Co s a with comply with those provisions.
"._Date: /%dy//� Applicant:
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 0100,000). 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 omissionrelated 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 construc ' tend hereby authorize representatives
of this county to enteruponthe above-mentioned grope r ion purposes.
%Signature (Applicant or Agen
Application Number . . . 10-00000422
,. Permit . . . . WALL/FENCE PERMIT
,. Additional desc •.
Permit -Fee' 15.00
Plan.Check
Fee
.00 .
Issue Date . . . .
Valuation
. .
. 400
Expiration Date 11/09/10
Qty Unit Charge Per
Extension
BASE FEE
15.00.,
Special Notes and Comments'
16 LN FT X 6 FT HT BLOCK WALL PER .CITY
STANDARDS & APPROVED.PLANS. APPROVED'
:PLANNING J-: W.- - - -• --- --- —. -- --
. Other Fees . . . . . ... BLDG STDS ADMIN (SB1473)
1.00
Fee summary. Charged Paid
Credited
Due
Permit Fee Total 15.00
.00
00
15.00
Plan Check Total .00
.00
.00
.00
Other Fee Total 1,.00
.00
.00
1.00
_ Grand Total 16.00
.00
.00
16.00
Bin #
Qty. Of La Quinta
Building 8I' Safety Division
P.O. Boz 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
L
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Project Address: 0d k
Owner's Name:
A. P. Number:
Address: Ov 9'Legal
7—�33
Description:
City, ST, Zip: C�
Contractor.1;hw..<{:.
Telephone: c�3g n^,�:< `::., .•
Address:
Project Description:
City, ST, Zip:
a /
Telephone:
City Lic. #:
State Lic. # :
Arch., Engr., Designer.
Address:
City., ST, Zip:
Telephone:
State Lic. #:
dY:,Gvf4` S'fl -S"t
Qr ;rs• k•
K.f �t£ %c<?f'a fry ii • NvN
Construction T e: Occupancy:
Project type circle one New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
#Stories:
#Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cales.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
20° 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:-
'rd Review, ready for corrections/issue
Developer Impact Fee
'Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
LA Q(J['NTA' CALIFORNIA. 92247.-1504
78-495 CAL.LE.TAT4PI,C,0
LA QUINTA', CALIFORNIA '92253
Go
BUILDING & SAFETY DEPARTMENT
(7'60) 777-7012..
FAX (760) 777-7011
YOWNER'S PACKAGE
'Disclosures & Form s for Owner -Builders Applying f -or Construction Permits
IMPORTANT! NOTICE T.2' PROPERTY OWNER
-Dear Property Owner:
An .--application fora building permit 6 been submitted in y list iurself as the builder of the property
-improvements specifiedat
9ur name�L
Wr e — zmo r Ar,/"(., . -
- are providing You with an _qwner.-Builder. Acknowledg-
ment and Information Verification Form tornake you awaie of your
.responsibilities and possible risk.
You may incur by having this pernu-t issued in your name as the
OV'Awr-Builder. We will not i.sstte-a building.pernlit until, youl. 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 ACIGqOWLEIDGMENTAND IERMCAT . ION OF M- ORMATION.
EVIRECTIONS: Read an&initial each statement below to signify you understand rstand or venfy this information.
A-01. I understand a frequent practice of unlicensed persons is to . have the property owner obtain an "Owner -Builder"
I
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 prope
rty-.My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder and ar-aware of the limits of my insurance
coverage for injuries to workers
-on. my property- .
1 understand building perriiits 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 responsibilitfy-
I understand as, an "Owner -Builder" I -am the res i le is and that I may
ponsib party of record on the permit. 11unde t 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.
I understand Contractors are
required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
J�a. 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"
understate and federal law.
�6. 1 understand if I am considered an "employer" under state and federal- law, I must register t
wi h 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 fiilure to abide by these law's may subject to serious financial
ris
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
structures' cannot legally build them with. the intent r
* to offer 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.
t,
I understand as an Owner -Builder ift.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.
` 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 (CSL.B) at I-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
�0. I am aware of and consent to an, Owner -Builder building permit applied for in my name, and understand that I am the
party le lly and furan ' uy . re onsi a for propo truction activity it the following address:
-- -
L 1. agree that, as the party. legally and financially responsible for this proposed construction.activity,.l will abide by all
plicabte laws and requirements that
govern: Owner-Buildersas 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 uncivil 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. issaittg, the permit Note: A. of the property owner's driver's -license, form notarization; or
other verification acceptable to. the a cy is required to be .presented when the permit is issued to verify the property
owner's signature.
Signature of property owner Date:
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 permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ONTROPERTY OWNER'S BEHALF
Excluding.the Notice to Property Owner, the execution of which I understand. is my personal responsibility,) hereby authorize
-the following person(s) to act as. my agents) 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):
Project Location or Address:
Name of Authorized Agent: Tel No
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 of the 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..
Property Owner's Signature: Date:
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