BSPN2016-005778-495 CALLE TAMPICO VOICE (760) 777-7125 C� D .
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760)777-7153.
BUILDING PERMIT
Date: 8/23/2016
Application Number: BSPN2016-0057 Owner.
Property Address: 53800 AVENIDA ALVARADO PAOLA HERNANDEZ
APN: 774154007 53800 AVENIDA HERNANDEZ
Application Description: PAOLA HERNANDEZ / IID UTILITY RELEASE LA QUINA, CA 92253
Property Zoning:
Application Valuation:
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Applicant:- Contractor: q
PAOLA HERNANDEZ AUG 2 3 2016 1
53800 AVENIDA HERNANDEZ
!-A QUINTA, CA 93253 CITY OF LA QUINTA
COMMUNITYDFVELOPMEN- DEPARTfAENT
Llc. No.:
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, r
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
per 't subjects the applicant to a civil penalty of not more than five hundred dollars
<(I, as owner of the property, or my employees with wages as their sole
c ,mp nsation, 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
she did not build or improve for the purpose of sale.).
r(I, as owner of the property, am exclusively contracting with licensed contractors
t 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
they on, and who contracts for the projects with a contractor(s) licensed pursuant to
t ntractors' State License Law.).
( am exempt under Sec. B.&P.C. for this reason
cDate: 0�jIV 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
Lender's
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 polity 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, DAMAGESAS 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 r ating to building
construction, and hereby authorize representatives of this city to enl upon the
above-mentioned property for inspection purposes.
23 �o
Date: Signature (Applicant or Agen
3
Date: 8/23/2016
Application Number: 'BSPN2016-0057
Owner:
Property Address: 53800 AVENIDA ALVARADO
J PAOLA HERNANDEZ
APN: _ 774154007
53800 AVENIDA HERNANDEZ
Application Description: PAOLA HERNANDEZ / IID UTILITY RELEASE
LA QUINA, CA 92253
Property Zoning:
Application Valuation:
Applicant:
Contractor:
PAOLA HERNANDEZ
53800 AVENIDA HERNANDEZ _
LA QUINTA, CA 92253.
Llc. No.:
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i
Detail: IID ELECTRICAL UTILITY RELEASE.
•NCIAL -INFORMATION
DESCRIPTION ACCOUNT CITY AMOUNT
SPECIAL INSPECTION 101-0000-42404 0 $72.52
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION: $72.52
TOTALS: $72.52