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12-0005 (ELEC)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 12-00000005 Property Address: 52555 AVENIDA CARRANZA APN: 773-285-015-2 -000000- Application description: ELECTRICAL Property Zoning: COVE RESIDENTIAL Application valuation: 1000 T4&t 4 4 a" BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Owner: . MOLLER LISA 52555 AVENIDA CARRANZA LA QUINTA, CA 92253 Contractor: Applicant: Architect or Engineer: Owner ----------------------- �� k 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.: 7�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 aapplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 0500).: (s 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.). (_ I 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.). (_ ) I am exempt under Sec. , B.&P.C. for this reason Date: IIA41 1� Z Owner: — 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 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760)_777-7153 Date: 1/04/12 JAN 0 4 2012 CITY OF LA QUINTA ,FINANCE REPT. WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 1. 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 ify 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 X31700 of the Labor C2W I shall forthwith comply with those provisions. ,Date: I r Applicant• WARNING: FAILURE TO SECUR 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 160 days from date of issuance of such permit, or cessation of work for 160 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 co.. fnty tomtenter upon the above-mentioned propert inspection purposes. %Date: T /� Signature (Applicant or Agent). LQPERMIT Application Number . . . . . 12-00000005 Permit . . . ELEC-SERVICE CHANGE. Additional desc . Permit Fee . . . . 33.50 Plan Check Fee .00 Issue Date Valuation . . . . 0 Expiration Date.. 7/02/12 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 18.5000 EA ELEC.SVC <=600V/<=200A 18.50 ---------------------------------------------------------------------------- Special Notes and Comments 200AMP SERVICE PANEL UPGRADE. 2010 CALIFORNIA ELECTRICAL CODES. January 4, 2012 2:33:33.PM AORTEGA ---------------------------------------------------------------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited --------- ---------------------------------------------- Due- ue•----------------- 77 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 P•.O. Box 1504' LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 PROPERTY O` NEWS PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures di Forms for Owner-Bullders Applying for Construction Permit's 4WIVETAN7'! MQ11Cl, TO PROPERTY Q)MR Dear Property Owner: Ern application for a building permit has sub�your name listing yourself as the builder of the property improvements specified at�I �itOl ir+ We are providing you: with an Owner -Builder Acknowledgment—and. Information Veri€eatioa Fort, to make you aware of your responsibilities and possible risk- you may incur by having this permit icedin your name as the Owns -Builder. We wifi not issue a building permit until you -have read, Init sled your understanding of ea ch'proAsion., signed, and returned this form to us at our etUcial address indicated. An agent of the owner cannot execute this>notice unless you, the property owner, obtain the prior approval of the permitting authority. OZ'S A_QQg0 EDMWT AND * WVWATMQ1� II'W N DIRECT 01a Read amd initial each statemeitt below to signify you undw3twO or verify this infornutdon. 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" uilding permit that erroneously implies that the property owner is providing his or her own labor and material personaft- I, as an Owner -Builder, may be held liable and subject to seriou$ 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 a y p2. I understand building permits are not required to be signed by property owners unless they are responsible for the truction and are not hiring a licensed Contractor to assume this responsibility.. . understand as an "Owner -Builder" I am the responsible party of rmord on the permit. I understand that I may protect if from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. �IZders tand Contractors are required by law to be licensed and bonded in California and to list their license numbers on .contracts. understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value ifnM-y5-construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. I understand if I am considered an "employer" under state and .federal taw, I must register with the state and federal overnment, 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 under California Contractors' State License Law, an Owner -Builder who builds single-family residential aj��.—understand 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. 8. 1. understand as an Owner -Builder if I sell the property for which this pernnit_'is issued, I may be held liable dor any inancial or. personal..ijseies sustained byany subsequent owuer(s) that. result from any latent construction defects in the Vlanor. materials. . erstand I, may 'obtain more infoiruation regarding my obligations as an "employe' trom'the lnteraatReUnited'.Staies Small. Business Administration, the" Catiforiva Department of'Benefit:Faymetits, and the California' Division. of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSL13) at 1- 800-321-0 (27 52) 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 1 am the party legally and financially responsible for . proposed . construction activity at the following address: ,rli of rra m 7.i 11. [ agree that, as.the party legally and financially responsible for this proposed.consttuction activity, I will abide by all plicable ' and requirements that govern Owner -Builders as well as employers. KII agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the information I ided on. thr;s form Licensedcontractors are regulated by laws designed to protect the public. If you contract with who does >�ot 6ave.a lie se, the Contractors' State License Board- may be unable to assts you with any 8na wM toss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be In -civil ootnt It also important for. you to understand that if an untiot nsod.Conawtor or employee of that individuat or Suis injured while wortring on your property;. You may behold liable for damages. If you obtain a permit as Owner -Builder and wish to hint Contractors, you will be Vie. fer verdYing vAwther or not those Contractors are properly Heensed and the status of dart wmkers' oompensation insurance coverage. Before a building permit: can be issued, this form mast be completed and signed by the property owner and returned to the agency responsible for issuing; ilea .permix. lYote: A copy of fire property owitff's diti€rri ,'r,e+ form a+ or other verification acceptable to the agency is requa+ed to be presented when the peamit is issued to'ver* dw paapeM owner's signature. Signature of property owner Date: Note: Ae following Authorization For7n 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 OWNEWS p�F Excluding the Notice to Property Owner, the exemtion of which I understand is my personal responsibility, I hereby authorize the following peraon(s} to act as my agent(s) to appl for; riga, and the documents to o tut O Builder Permit for my project. Scope of Construction Project (or DesFtip�ioh' off: $' Project Location or Name of Authorized-Agen Address of Authorized Ag I declare under penalty of information and cettify its acceptable to the agency i Property Owner's Signatu property owner's signature.. � All'n, Bin # City,of La Quinta:' '. Building 8f Safety Division P..O. Box 1504, 78-495 Calle Tampico-� La Quinta, CA 92253 _ (760) 777-7012 Building Permit Application and Tracking Sheet Permit # 12- eoo5 Project Address: Owner's Name: I—l5q Mo //W • A. P. Number: Address: p? 6,6 5tl,�/0 ! rr Legal Description: z. City. ST, Zip:1a Gj//Jt Contractor. TeleP}tone:' �:. ;, Address: r-rojpct Description: G City, ST, Zip: Tele hone: State Lie. # : City Lie. C Arch., Engr., Designer. ' Address: i City, ST, Zip: Telephone::� _ �. M .. .ax <-; '. Construction T O,,.,,,,upa,, State Lie. #: 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: 0 APPLICANT: DO NOT WRITE BELOW THIS UNE # Submittal Req'd Rec'd TRACMG PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calm Reviewed, ready for corrections Plan Check Deposit Truss Cales. Called Contact Person Plan Cheek Balance Title 24 Calm Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2'' Review, ready for correctious/issue Electrical Subeontector List Called Contact Person Plumbing Grant Deed Plans picked up SMI. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- ''� Review, ready for corrections/issuc Developer Impact Fee Planning Approval Called Contatt Person A.I.P.P. Pub. Wks. APer Date of permit issue 1 q School Fees Total Permit Fees