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11-0777 (ELEC)`P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 "`&t!t 4 4 4" BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Application Number: !! 11-00_000777_ L Property Address: 46855 HIGHLAND PALMS DR APN: 643-191-008-8 -2117 - Application description: ELECTRICAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 550 Applicant: CW Architect or Engineer: ------------------ 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—) 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.). ( s 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 coracts for the projects with a contractor(s) licensed n pursuant to the Contractors' State License .1. ( /f, am exempt under Sec. , B.& or this reaso T f Date: Owner: I ' 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 ISec. 3097, Civ. C.1• Lender's Name: Lender's Address: LQPERMIT Ii VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 7/18/11 Owner: UNDERWOOD JACQUELINE G 46855 HIGHLAND PALMS DRIVE LA QUINTA, CA 92253 --------------------------------- Contractor: Owner D)r— L1 Fn --------------------E--_M:_18 2011 OF LA ----------------------------------------------— 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 Numb i% I certify that, in the performance of the work f hich this permit is issued, I shall not employ any person in any manner so as to become subj c to the workers' compensation laws of California, and agree that, if I should be a subject a workers' compensation provisions of Section 7th 00 of the Labor Cod fort ith ply with those pprov' ions. Date- /V //-Applicant: WARNIN : F (LURE TO SECURE WORKERS' COMPEN ATION 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 Ouinta, 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 wor s not commenced within 180 days from date of issuance of sucepermit, ation of wo f r 180 days will subject permimo cancellation. 1 certify that I have read this application and state that the n is torr t. 6 agree to comply with all city and county ordinances and state laws relating to buildia d her �uthorize representatives of this cou to nter upon the above-mentioned pro osas Date: 1 Signature (Applicant or Agent): Application Number . . . . . 11-.00000777 Permit . . . ELEC-SERVICE CHANGE Additional desc Permit Fee 33.50 Plan Check Fee .00 Issue Date . . . . Valuation 0 Expiration Date 1/14/12 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 18.5000 EA. ELEC SVC <=600V/<=200A 18.50 ---------------------------------------------------------------------------- Special Notes and Comments ELECTRICAL METER CHANGE OUT 200AMP SAME FOR,SAME. 2010 CODES -------------------------------------------------------------- Other Fees . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged - Paid Credited -- Due - ------- - -------- ---------- 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 P.O. Box 1504 ` LA QUINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT 78-495 CALLS TAMPICO (760) 777-7012 LA QUINTA, CALIFORNIA 92253 PROPERTY O'WNER'S PACKAGE FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits �Gl_► —PORTANT! NOTICE TO PROPEI%TX OWNER Dear Property Owner. Ari. 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 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. OMMEWS ACKNOWLEDGMENT AND'VERIFICATION OF.INFORMATION DIRECTIONS: Read and initial eachstatement below to signify you understand or verify this information. r� 1. I understand a_fr6quent practice of unlicensed persons, is. to have the property owner obtain an "Owner -Builder" "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 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. V 2. I 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.. `�'� iI�1 I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect inysel€ from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on its and contracts. f1 IV 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value iSf my construction is at least five hundred dollar -s-($500), including labor and materials, I may be considered an "employer" und er state and federal law. 6. I understand if I am considered an "employer" under state and federal law, I must register with the state andfederal , 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. VL7. 1 understand under California Contractors' State License Law, an Owner -Builder, who builds single-family residential structures 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. ���V��8. 1 understand. as an Owner -Builder if I sell the property for which this permit is issued,'l may .be held liable for any lPinancial or personal. injuries sustained. by any subsequent owner(s) that result from any latent construction defects in the, workmanship or materials. ' �Q 9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue. . .45ervice, 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 (CS -LB) at 1- 800-321-CSL13 (2752) or www.cslb.ca.gov for more information about licensed contractors. L) 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the Pant legally and financially responsible for proposed construction activity at the following address: that, i l. I a as the g � t, party legally and financially responsible for this proposed construction activity, [ will abide by all pplicable laws and requirements that govern Owner -Builders as well as employers. J 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I ave 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 worlang on your property; you may be held_ liable for damages. If you obtain a permit asOwner-Builder and wish to hire Contractors, you will be r€sponsibke for verifying whether or not .those Contractors are properiy 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 issaing,tlhe.permit. Note: A copy of the property owner's dkiver'sIkensei form o��ricaftgn; or Other veriftcadon acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Signature of property owner &C Date: (— 1? L L 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 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): 2�O(�) A a -i' M -e Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: q(o S ss j�, q (A Ad s , �D-r I declare under penalty of perjury that I am the property owner for the address listeg 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: Bin # City of LaQ uin tQ Building & Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # \� Project Address: -S-5 � l,q ,ted od77 7. Owner's Name: LYS u d W a A. P. Number: Address: V6 �'� s N, h / Legal Description: Contractor:f<•;:;,;.:;:•;:.;:.;;:.;:.:.;:.:;•;•»zz:«?•;:.>:..:;: D Ci - ty, ST, Zip: 1- �► v rt,l Telephone: Address: Project Description: City, ST, Zip: Telephone: /\ C-- 47� State Lie. # : City Lie. Arch., Engr., Designer: I Address: City, ST, Zip: Telephone: State Lie. #:«;:?:':::':::::<:<"<:r<:>>'#<:;��<.• :`.>:<?>:>.:;::::<:<:<;•:<<:•>: • > Name of Contact Person ' bevL Construction T Project type (circle one): New Add'n Alter Repair Demo Sq. Ft.: # Stories: # Units: Telephone # of Contact Person: Estimated Value of Project: S v APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Coles. Reviewed, ready for corrections Plan Check Deposit Truss Cales. Called Contact Person Plan Check Balance Title 24 Cafes. Plans picked up Construction Flood plain plan Pians resubmitted Mechanical Grading plan 20. Review, ready for correctionstiissue 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