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BPLB2016-009678-495 CALLE TAMPICO C� Q D LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT BUILDING PERMIT Application Number: BPLB2016-0096 Owner: Property Address: 78685 AVENIDA NARANJA ROLLAND REGNERY APN: 770106003 P 0 BOX 234 Application Description: ROLLAND REGNERY / GAS LINE CONECTION LA QUINTA, CA 921 Property Zoning: Application Valuation: $4,500.00 Applicant: ROLLAND REGNERY P 0 BOX 234 LA QU11`17A, CA 922`'3 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 Professions Code, and my License is in full force and effect. License Class: _ license No.::CONV:140528101254129252 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 any applicant for a fersubjects-the applicant to a civil penalty of not more than five hundred dollars s owner of the property, or my employees with wages as their sole sation, will do the work, and the structure is not intended or offered for sale. 44, Business and Professions Code: The Contractors' State License Law does not 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 w' one year of completion, the owner -builder will have the burden of proving that she did not build or improve for the purpose of sale.). I, as o ner of the property, am exclusively contracting with licensed contractors o cons ruct 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 an n,and who contractsfor the projects with a contractor(s) licensed pursuant to tractors'State License Law.). am exempt under Sec. P.C. fort is r son � r / Date: CONSTRUCTION LE DIN AGENCY I hereby affirm under penalty of perjury tha her is a construion lends a ncy for the performance of the work for which this permit issued c. 3097, Civ. C.). Lender's Name: Lender's Contractor: ROLLAND REGNEF P 0 BOX 234 LA QUINTA, CA .92 VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 7/5/2016 nA JUL 0 5 2016 CITY 0Hj, Qyj;vTA 1"IJRITY CEycLOc';'��'ctiT d1��:T ".t=tiT (760)702-6409 Llc. No.::CONV:140528101254129252 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, I shall forthwith comply with those provisions. Date: 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 ($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 Building Official 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 representativ above- m ntio d property for inspection purpose Date: I Signature (Applicant or FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00 7/5/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY ROLLAND REGNERY CHECK R16766 2313 RSE Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 $1.00 DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE PERMIT ISSUANCE 101-0000-42404 0 $91.85 $91.85 7/5/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY ROLLAND REGNERY CHECK R16766 2313 RSE Total Paid for PERMIT ISSUANCE: $91.85 $91.85 A JESCRfFjitiiJ`°�' ACCOUNT QTY" AMOUNT PAID PAID DATE GAS SYSTEM; 5+ OUTLETS 101-0000-42401 0 $36.26 $36.26 7/5/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY ROLLAND REGNERY CHECK R16766 2313 RSE DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE GAS SYSTEM, 5+ OUTLETS PC 101-0000-42600 0 $24.17 $24.17 7/5/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY ROLLAND REGNERY CHECK R16766 2313 RSE Total Paid for PLUMBING FEES: $60.43 $60.43 TOTALS: $153.28 $153.28 Description: ROLLAND REGNERY / GAS LINE CONECTION Type: PLUMBING Subtype: Status: ISSUED Applied: 7/5/2016 RSe Approved: 7/5/2016 Rk Parcel No: 770106003 Site Address: 78685 AVENIDA NARANIA LA QUINTA,CA'92253 Subdivision: DESERT CLUB TR UNITS Block: Lot: 115 Issued: 7/5/2016 RSE 7 Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $4,500.00 Occupancy Type: Construction Type: Expired: 1/1/2017 RS-7- S-No. No.Buildings: 0 No. Stories: 0 No. Unites: 0 ROLLAND REGNERY Details: LA QUINTA CA 92253 Printed: Tuesday, July 05, 2016 8:35:50 AM 1 of 2 . SYS TERAS CHRONOLOGY NAME TYPE NAME ADDRESSI CONDITIONS CONTACTS CITY STATE ZIP PHONE FAX EMAIL APPLICANT- ROLLAND REGNERY P 0 BOX 234 LA QUINTA CA 92253 (760)7Q2-6409 CONTRACTOR ROLLAND REGNERY P 0 BOX 234 LA QUINTA CA 92253 (760)7Q2-6409 OWNER ROLLAND REGNERY P 0 BOX 234 LA QUINTA CA 92253 (760)702-6409 Printed: Tuesday, July 05, 2016 8:35:50 AM 1 of 2 . SYS TERAS INSPECTIONS PARENT PROJECTS Printed: Tuesday, July 05, 2016 8:35:50 AM 2 of 2 V? SYSTEMS CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY BY PERMIT ISSUANCE 101-0000-42404 0 $91.85 $91.85 7/5/16 R16766 2313 CHECK ROLLAND REGNERY RSE Total Paid for PERMIT ISSUANCE: $91.85 $91.85 GAS SYSTEM, 5+ 101-0000-42401 0 $36.26 $36.26 7/5/16 R16766 2313 CHECK ROLLAND REGNERY RSE OUTLETS GAS SYSTEM, 5+ 101-0000-42600 0 $24.17 $24.17 7/5/16 R16766 2313 CHECK ROLLAND REGNERY RSE OUTLETS PC Total Paid for PLUMBING FEES: $60.43 $60.43 TOTALS: INSPECTIONS PARENT PROJECTS Printed: Tuesday, July 05, 2016 8:35:50 AM 2 of 2 V? SYSTEMS B`" # City of La Quinta Buifding 8t• Safety Division 78-495.Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit 4# Project Address: Owner's Name: A. P. Number: Address:`1 Legal Description: City, ST, Zip:. �� a ra r• Cont ct o. 6 'e V TeleP hone: Address: Project Description: City, ST, Zip:LQNL Telephone: hone: State Lie. # : City Lie. #: Arch., Engr., Designer: Address: City,, ST, Zip: Telephone: .......................... .......... Construction Type: Occupancy:an cy: t to Lie. #• Sa P roJ'ect 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: 41 v APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Cates. - Called Contact Person Plan Check Balance Title 24 Calcs. 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:- '"! 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 .,i Tw�p 4 4 4" 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 IMPORTANT. NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a buildin permit has been submitted inour na isting yourself as the builder of • the property improvements specified at " Y. We are providing you with an Owner -Builder Acknowledgment and infonnatiofi Verificatibil 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 signi you understand or verify this information. k�p 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" uil mg 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. Pn a 2. I understand building permits are not required to be signed by property owners unless they are responsible for the co ction. and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner -Builder" I am the responsible party of record on the permit_ I understand that I may protect ys f from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my (� own. l/ 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on its and contracts. 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. 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.. PS127. 1 understand under California Contractors' State License Law, an.Owner.-Builder who builds single-family residential strucftwes 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. ,18-4 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for an P Y y financial or personal injuries sustained by any subsequent owner(s) 'that result from any latent construction defects in the 4ervice, anship or materials. I understand I may obtain more information regarding my, obligations as an "employer" from the Internal Revenue a 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- 800-32 1 -CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 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 ally : and financ' ll responsible for ro o d cons , , M Y P It _ ,N _ P construction activity at the following address: bY 1. I agree that, as the party legally and financially responsible for this osed construction activity, I will abide by all applicable laws and requirements that govern Owner_Builders asmell as employers. 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 accep the agency .is required to be presented when the permit is issued to verify the property owner's signature. Signature of property er 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 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): Project Location or Address: Name of Authorized 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 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 owners signature. Property Owner's Signature: Date: /q ti PAU- (9, cu X 41 �f 0 6 ovtLF S fV OF LAQUINTA ILDING & SAFETY DEPT. APPROVED FOR CON RUCTION Ts. - c� ALL- PIpF, Will or, gj- N -V,�j X-TTic