09-0886 (SOTB)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T,iht 4 4 Q"
Application Number:
09-00000886
Property Address:
79338 CETRINO
APN:
772-120-037- - -
Application description:
STRUCTURES OTHER THAN BUILDINGS
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
950
App�licant::r,�/�/ 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 (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 permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_ 1 1, 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 lice contractors to construct the project (Sec.
7044, Business and Professions Code: The ontractors' ate cense Law does not apply to an owner of
property who builds or improves thereon, d who contr cts f the projects with a contractor(s) licensed
pursuant to the Contractors' State Licens La : ).
(_) I am exempt under Sec. , B.&P.C.or is reas
Date:
Owner:
I hereby affirm under penalty of perjury that th is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 309 iv. C.).
Lender's Name: _
Lender's Address:
LQPER1111T
Owner:
ROGERS, GREG
ROGERS FAMILY
SAN DIEGO, CA
(
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/19/09
TRUST
92126
------------------------------------`--------
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
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 nu ber are:
Carrier - - -.- - - - - - - - - - - - - - - - - -- Policy Number
Certify that, in the performan of the work fo } ich this permit is issued, I shall not employ any
person in any manner so a t become su �fto the workers' compensation laws of California,
and agree that, if I sho
F /1 3700 of the Labor C
Date: ` �7 Q Applicant:
WARNING: FAILURE TO SECUR
SUBJECT AN EMPLOYER TO CR A
DOLLARS ($100,000). IN ADD N T
SECTION 3706 OF THE LABO DE,
the workers' compensation provisions of Section
nply with those provisions.
Camp �1if$ATION COVERAGE IS UNLAWFUL, AND SHALL
L P ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
0 HE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
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 d to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application beco es ull and id if wor is not commenced
within 180 days from date of issuance of such pe it, r cess on of wor for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the ove in rm on is correc I agree to comply with all
city and county ordinances and state laws relating to buil ' g co uc ' , and her authorize representatives
of this co/ ty o enter upon the above-mentioned proper f r ' p purpos
Date 1 0 Signature (Applicant or Agen .
Application Number
Permit . . . .
Additional desc .
Permit Fee . . .
Issue Date . . .
Expiration Date .
. . . . 09-00000886
BUILDING PERMIT
25.00
2/15/10
Plan Check Fee . . 16.25
Valuation . . . . 950
Qty Unit Charge Per Extension
BASE FEE 15.00
5.00 2.0000 HND BLDG 501-2,000 10.00
----------------------------------------------------------------------------
Permit . . . ELEC-MISCELLANEOUS
Additional desc .
Permit Fee 15.75 Plan Check Fee 3.94
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 2/15/10
Qty Unit Charge Per Extension
BASE FEE 15.00
1.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20 .75
---------- :
. . . PLUMBING
Additional desc .
Permit Fee . . . . 18.00 Plan Check Fee 4.50
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 2/15/10
Qty Unit Charge Per Extension
BASE FEE 15.00
1.00 3.0000 EA PLB FIXTURE DRAIN/VENT REP/ALT 3.00
------=---------------------------------------------------------------------
Special Notes and Comments
INSTALL GAS LINE & ELECTRICAL LINE TO
BBQ 200 LN FT. & (2) ELECTRICAL
OUTLETS. APPROVED BY A.J.
---------------------------------------------------------------------------
Other Fees . . . . . .. . . . BLDG STDS ADMIN (SB1473) 1.00
ENERGY REVIEW FEE 1.63
Fee summary Charged
Permit Fee Total 58.75
Plan Check Total 24.69
Other Fee Total 2.63
Grand Total 86.07
LQPERMIT
Paid Credited Due
.00 .00 58.75
.00 .0.0 24.69
.00 .00 2.63
.00 .00 86.07
I�
P.O. BOX 1504
LA QUINTA; CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(7'60) 777-70.12
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 building permit has been submitted in your name listing yourself as the builder of the .property
improvements specified at
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible riskyou may incur by having this permit -issued in your name as the
Owner -Builder. We will not issue a buildingpermit until yoa,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 signify you understand or'verify this information.
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
.b aing permit that erroneously implies that the property owner is providing his or her own labor and material personally. 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
injures. 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.
understand building permits are not required to be signed by property owners unless they are responsible for the
c struction and are not hiring a licensed. Contractor to assume this responsibility.
&ysel
understand as an "Owner-BuilderJ am the responsible.party of record on the permit. I understand that I may protect
om potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
12-11 understand Contractorsare required by law to be licensed and bonded in California and to list their license numbers on
pe is and contracts.
I understand if I employ or otherwise engage any persons; other than California licensed Contractors, and the total value
y-cornstruction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
��Yunderstand 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, andcontribute to unemployment
compensation for each "employee." I also understand 'my failure to abide by these laws may subject me to serious financial
risk.
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
(_�:&c?tels 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.
understand
as an Owner -Builder if I sell the property for which.this permit is issued, I may be .held liable for any
r personal. injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
4,cel
understand I may obtain more information regarding my obligations as an "employee' from the internal Revenue
ethe 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-
800-321-CSLB (2752) or www.csib.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
legally and financially responsible . for proposed construction activity at the following. address:
Zi
1_ I agree that, as the party. legally and financially responsible for this proposed. construction activity,.I will abide by all
a able taws and requirements that govern Owner -Builders as well as employers.
e12. 1 agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the information I
ave ovided 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, #Is .ttirm mus{be c mpleted and signed by the property owner and returned to
the agency responsible for issniug; the. r '. NotelA co . of the property owner's driver.'s.ticense; farm notarization; or
other verification acceptable to the n is r wired o be presented when the permit is issued to verify the property
owner's signature.
Signature of property owner Date: D
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 responsib-ility, 1 hereby authorize
the following person(s) to act as, my agent(s) to apply for, sign, and f le 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 Co be presented when the permit is issued to verify the property owner's signature -
Property
Property Owner's Signature: Date:
Bin #
ty of La Quiilta
-Building ar Safety Division
P.O. Box 1504, 78-495 Calle Tampico
to Quinta, CA 42253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
L] L
Project Address: " 3 � (�; 1 h�
dwner's Name: C'e. r S 1 t S
A- P_ Number. 01 L4 `7
Address: 7 oZ efUiL OGUZ4_ -,
Legal Description: 'f"i+
City, ST, Zip: "Ic Z
Contractor LJ / �,� L �Ci�LX
Telephone
Address: CI ' J 3 b U +T- up (j
Project Description:
City, sr, Zip:. l 1.L 1 il- 1 ,;10 :63
1 k -)CSS-.-Q C.I e dr,
Telephone: -��g 13z)0)
• -->y -�>F
-�
! t nQ
State Lic. 9:
City I.ic. 9,.
Arch:, Engr., Designee:
vD
Address:
City, ST, Zip:
-
Telephone:
y: P.'�-` ,..,�
1M �: =
r
Construction Type: Occupancy:
State Lic_ #:-
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: 9 160
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
ReQ'd
Reed
TRACMG
PEnUT'FEES
Pian Sets
Plan Check submitted
Item
Amount.
Structural Cates.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cates.
Called ContactPersou
Plan Check. Balance
TitfeUCalcs.
Plans picked :up
Construction '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
.2'! Review, ready for correctionslissue
Electrical
Subcontactorudst
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M:I.
ILO.A. Approval
Plans resubmitted
Grading
IN HOUSE-
''� ReAtw, ready for correctionst'6ssue
Developer Impact Fee
planning Approval.
Called ContaetPerson
A.IX.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
i r'uS•}
I
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