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BWFE2016-0089LICENSED 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, and my License is in full force and effect. License Class: _ License No.::CONV:140528101254140702 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 (I, as owner of the property, or my employees with wages as their sole G compensation, will do the work, and the structure isnot 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&0 Cas owner of the property, am exclusively contracting with licensed contractors l 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.). (0&I am exempt under Sec. . B.&P.C. for this reason > 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 Na 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 policy number are: Carrier: Policy Number: _ 't f 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 se provisions. Date: �/ �C7 I 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, 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 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 relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (Date: :� O Signature(ApplicantorAgent) I 78-495 CALLE TAMPICO D VOICE (760)_777-7125 LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 4/5/2016 Application Number: BWFE2016-0089 Owner: Property Address: 52015 AVENIDA ALVARADO MIGUEL JIMENEZ APN: 773213012 52015 AVENIDA ALVARADO Application Description: JIMINEZ CERDA / 114LF OF BLOCK WALL LA QUINTA, CA 92253 Property Zoning: Application Valuation: $3,500.00 Applicant: Contractor: MIGUEL JIMENEZ MIGUELAMENEZ mp x:31 52015 AVENIDA ALVARADO 52015 AVENIDA ALVARADO z LA QUINTA, CA 92253 LA QUINTA, CA 92253 o rn of >; rn (760)574-9481 Llc. No.::CONV:140528101254140702---- ---�` 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, and my License is in full force and effect. License Class: _ License No.::CONV:140528101254140702 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 (I, as owner of the property, or my employees with wages as their sole G compensation, will do the work, and the structure isnot 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&0 Cas owner of the property, am exclusively contracting with licensed contractors l 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.). (0&I am exempt under Sec. . B.&P.C. for this reason > 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 Na 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 policy number are: Carrier: Policy Number: _ 't f 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 se provisions. Date: �/ �C7 I 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, 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 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 relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (Date: :� O Signature(ApplicantorAgent) FINANCIAL •• • DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 PAID BY METHOD RECEIPT* CHECK # CLTD BY Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 $0.00 DESCRIPTION ACCOUNT QTY AMOUNT PAID PAIDDATE WALL/FENCE - EA ADDITIONAL 50 LF 101-0000-42404 0 $14.50 $0.00 PAID BY METHOD RECEIPT# CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE WALL/FENCE - FIRST 100 LF 101-0000-42404 0 $47.86 $0.00 PAID BY METHOD RECEIPT_ # CHECK # CLTD BY DESCRIPTION , ACCOUNT QTY AMOUNT PAID PAID DATE WALL/FENCE - FIRST 100 LF PC 101-0000-42600 0 $60.91 $0.00 PAID BY METHOD RECEIPT '# CHECK# CLTD BY Total Paid for FENCE OR FREESTANDING WALL: $123.27 $0.00 TOTALS:00 Description: JIMINEZ CERDA / 114LF OF BLOCK WALL Type: WALL/FENCE Subtype: CITY STANDARD/PRE- Status: UNDER REVIEW Applied: 4/5/2016 SKH APPROVED Approved: Parcel No: 773213012 Site Address: 52015 AVENIDA ALVARADO LA QUINTA,CA 92253 Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 3 Lot: 1 Issued: UNIT 1 - PHONE Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $3,500.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 LA QUINTA Details: 114LF OF 5'/6' GARDEN WALL AT FRONT AND SIDE YARD'PL AND EQUPIMENT WALL. [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013 CALIFORNIA BUILDING CODES. anf11TInNAI SITFS CHRONOLOGY CONDITIONS NAME TYPE NAME ADDRESS1 CONTACTS CITY STATE ZIP PHONE FAX EMAIL APPLICANT MIGUEL JIMENEZ 52015 AVENIDA ALVARADO LA QUINTA CA 92253 (760)574-9481 CONTRACTOR MIGUEL JIMENEZ 52015 AVENIDA ALVARADO LA QUINTA CA 92253 (760)574-9481 OWNER MIGUEL JIMENEZ 52015 AVENIDA ALVARADO LA QUINTA CA 92253 (760)574-9481 Printed: Tuesday, April 05, 2016 5:20:07 PM 1 of 2 SYSTf:MS DESCRIPTION ACCOUNT. QTY : AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD —j' PAID BY CLTD BY BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 Total Paid for BUILDING STANDARDS•ADMINISTRATION 51.00 $0.00 BSA: WALL/FENCE - EA 101-0000-42404 0 $14.50 $0.00 ADDITIONAL 50 LF WALL/FENCE - FIRST 101-0000-42404 0 $47.86 $0.00 100 LF WALL/FENCE -FIRST 101-0000-42600 0 $60.91 $0.00 100 LF PC Total Paid for FENCE OR FREESTANDING WALL: $123.27 $0.00 TOTALS: $124.27 00 PARENT PROJECTS ATTACHMENTS Printed: Tuesday, April 05, 2016 5:20:07 PM 2 of 2 SYSTEMS Bin '# = City of La Qulnta Building & Safety Division 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # Project Address: Owner's Name: C A. P. Number: Address: ec& A u4r� o Legal ncsrription: City, ST, Zip: V• �., a s 3 Contractor: .:.. ... ._ ... Tcicphoiit: % . . Y ..n ... R Address: Project Description: City, ST, Zip: -. _... 6 114 LF . :.. Telephone. . fl. ! Y1 Yh .f�1X•. �sy ,Vi,y3X 2i J. .. .. y . Statc Lt . # : City Ltc #: . Arch., Engr., Designer: - Address: - City, ST, 'Lip:: Telephone: . f State Lic. #: s �s� Name of Contact Person: Construction Type: Occupancy`IN. Project type (circle one): New Add'n Alter Repair Demo Sq. Ft.; # Stories:: # Units. Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE N Submittal Req'd Reed TRACYJNIG PERMIT FEES Plan Sets Plan Check submitted , Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Cal cs. Called Contact Person Plan Cheek Balance , Title 24 Cates. Plans picked up Construction • Flood lain plan P. P Plans resubmitted Mechanical Grading plan 2n0 Review, read for corrections/issue Y Electrical Subcontactor List Called Contact Person Plumbing , Grant Decd Plans picked up H.O.A. Approval Plans resubmitted Grading IN IIOUSE:- '`a Review, ready for corrections/issue Developer Impact Fee PlanningApproval l I Called Contact Person A.I.P.P. Pub, Wks. Appr Date of permit issue School tees, - • •�' Total Permit Fees at QUM& 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)777-7012 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 buildin encu has b en submitted in your name listing yourself as the builder of the property improvements -specified at d Aueyk � die Y-4�r) We are providing you with anOwner-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. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to signify you understand or verify this information. tui 1. I understand a frequent 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. 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 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. M 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. J t 3. I understand as an "Owner -Builder" I ani the responsible party of record on the permit. I understand that I 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. -LKL4. )'understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. JU C 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. VLk(' 6. I understand 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, 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. Pk ('7. I 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. W 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries.. sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. vt( 9. I understand I may obtain more information regarding my'obligations as an."employer" from the Internal Revenue Service, 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 (CSLB) at 1- 800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. M10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally, and financially • responsible for proposed • construction activity at the • following address: r11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as.well as employers. W 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I 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 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, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property 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. Signature of property owner 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 far 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 persons) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Pemmit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: �,. sonally filled out the above or other verification owner's signature. SFS ? ` x �t�e J, '^ off h � r Y g � _ T c)0�� CITY O LA QUINTA BUILDING & SAFETY DEPT.. C4 --- APPROVED .FOR CONSTRUCTION DATEISLq&lk-13Y—& a uq LF- of. s' d lei �' G,-c•� �srM-ao�M� o .