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11-0331 (BLCK)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 11-00000331 Property Address: 52880 AVENIDA CARRANZA APN: 773-322-007-20 -000000- Application description: WALL/FENCE Property Zoning: COVE RESIDENTIAL Application valuation: 1250 Tiht 4 4 Q" Applicant: Architect or Engineer: .. oma,-��� . lu,4- ------------------ LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 t e or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by pplicant for a permit subjects the applicant to a civil penalty of not, more than five hundred dollars ($500).: 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 uilding or improvement is sold within one year of completion, the owner -builder will have the burden pro ing that he or she did not build or improve for the purpose of sale.). (_ 1 1, as owner of the property, am exclusively contracting with I' a ed ontrac rs to construct the project (Sec. 7044, Business and Professions Code: The Contractor tat icens aw does not apply to an owner of property who builds or improves there�e.) Contractor/ co ra for th rojects with a contractor(s) licensed pursuant to the Contractors' State LicI am exempt under Sec. , B.&PoS n Date: 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.I. Lender's Name: _ Lender's Address: LQPERMIT Owner: RICHMAN ALLEN VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 4/04/11 Contractor: D d Owner SPR 042011 l C— OFte....-_ 1 ------------------ 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 performa o the work for which this permit is issued. I have and will maintain workers' compensation in ance, as qti a by Section 3700 of the Labor Code, for the performance of the work for ich this per is' sued. My workers' compensation insurance carrier and policy number are: Carrier - - - - - - - - - - - - - - - - - - -- - - Poli Number _ I certify that, in the perfor work fo hi this permit is issued, I shall not employ any person in any manner comes e o the workers' compensation laws of California, and agree that, if I e.su ' e workers' compensation provisions of Section 3700 of the Lab 11 f comply with those provisions. Date: &&!% Applic JF 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 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 is ap lication, the owner, and the applicant, each agrees to, and shall defend, indemnify and,la d harmless a City of La Quinta, its officers, agents and employees for any act or omission r I ted to th r eing performed under or following issuance of this permit. 2. Any permit issued as a result of this appA old if is not mmenced within 180 days from date of issuancetion o ork for days will subject permit to cancellation. I. certify that I have read this application and state tho corr agree to comply with all city and county ordinances and state laws relating to , an eby authorize representatives of this countyy ttoo eennter upon the above-mentioned prrposes. Date: A4 , - Signature (Applicant or Agent): i Application Number . . . . . 11-00000331 Permit . . . WALL/FENCE PERMIT Additional desc . Permit Fee 31.00 Plan Check Fee .00 Issue Date Valuation . . . . 1250 Expiration Date. 10/01/11 Qty Unit Charge Per Extension BASE FEE 15.00 8.00 2.0000 HND BLDG 501-2,000 16.00 r--------------------------------------------------------------------------- Special Notes and Comments 50 LN FT X 6 FT HT GARDEN WALL TO CITY . STANDARDS AND APPROVED PLAN. ---------------------------------------------------------------------------- Other Fees . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited Due ------------------------------------- Permit Fee Total 31.00 -------------------- .00 .00. 31.00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 32.00 .00 .00 32.00 LQPERMIT V 4N'V a, 01 U -,0 I I ..... ..... -1 L i -T - F-- - L --IL -4-!! L EEE t 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) 177 -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 build t has been submitted your name listing yourself as the builder of the property improvements specified at g �y A V6 "d //N CAM /4/17– A We are providing you with an Owner -Builder Acknowledgment and information Verification ('onn 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. U` R'S ACI NOWL.EDGMENT AND VERIFICATION OF INFORM -A ON DCRECTIONS: Read and initial each statement below to signify you understand or verify (kis information. 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder' bui ding permit that erroneously implies that the property owner is providing his or her ovm 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. 2. 1 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. 3. I understand as an "Owner -Builder" 1 am the responsible party of record on the permit. l understand that t 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. tl . i understand Contractors are required by law to be licensed and bonded in California and to list their license numbers o permits and contracts. t-5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total vale of my construction is at least five hundred dollars ($500), including labor and materials, 1 may be considered an "employe under state and federal law. )L6. I understand if I am considered an "employer" under state and federal law, 1 must register with the state and fede government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unetttploym compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious finan4 risk. 7. 1 understand under California Contractors' State License Law-, an Owner -Builder who builds single-family residei structures cannot legally build them with the intent to offer them for sale, unless all work is performed by lice subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perfoi under contract with a licensed general building Contractor. In8. 1 understand as an Owner -Builder if 1 sell the property for µfilch this permit is issued, l may be held liable for any —a.cial or. personal igjuuies sustained by any subsequent owner(s) thatresult from any latent construction defects in the frkmanship or materials. _91 understand I may obtain more• information regarding my obligations as an "employer" from the Internal Revenue vice., the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. 1 also understand 1 may contact the California Contractors' State License Board (CSLB) at I- 00-321-CSLB (27 52) or www.cslb.ca.gov for more information about licensed contractors. 1 0. t am aware of and consent to an Owner -Builder building permit ap11 plied for in my name, and understand that I am the p y legally and financially responsible for proposed construction activity - at the following address: agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide by all cable laws and requirements that,govem Owner -Builders as well as employers. _ 12. l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 1 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 Dire Contractors. you will be responsible *for verifying whether or not thoseCors are properiy licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this fo the agency responsible for issuung mit other verification acceptable to cY f� owner's signature. Signature of property owner rst b eted and signed by the property owner and returned to A o of tke Property owner's driver's license, faun notaritafkaft, or a be presented when the permit is issued to verify the property ✓ a?t3l l 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 l u Aderstand is my personal responsibility, 1 hereby authorize the following person(s) to act asmy 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: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and l personally filled out the ab 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: pill it City of La Quinta Building &r Safety Division P.O. Box 1504, 78-495 Cage Tampico la Quinta, CA. 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # Project Address: Sa Q $Q Of 4if( AJ Zp Owner's Name: X11,-1)-�l l e17.'!A1 A. P. Number: Address: 2 g 7018 7lclA ,- I,I,A 1,J45 ST Legal Description: City, ST, Zip/�-,aq,0_} A'11/504 , 7/70/ Contractor: Can r L ,� Ce> e< E Tele e hon . � � Address: Project Description: ,%dk &)A T %/ !q City, ST, Zip: I Ct T Telephone: D r T d State Lic. # : City Lic. #; Arch., Engr., Designer: Address: City, ST, Zip: ne: Telephone:ho Construction Type: Occupancy: an cY State Lic. #: Project hP (circle cle one New Add'n Alter Repair Demo Name of Contact Person: Sq. Ft.: # Stories: # Units: Telephone # of Contact Person: Estimated Value of Project: 3 � APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Caics. Reviewed, ready for corrections Plan Check Deposit Tress Cities. Called Contact Person Plan Check Balance. Title 24 Cafes. 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. K.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