14-0769 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
14-00000769
Property Address:
81640 RUSTIC CANYON DR
APN:
764-280-999-29 -300237-
Application description:
PLUMBING
Property Zoning:
MEDIUM HIGH DENSITY RES
Application valuation:
50
Applicant:
Architect or Engineer:
------------------
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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
a applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (55001.:
() I, 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 1, as 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 contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.). _ -
1 _ 1 I am exempt under Sec. B.&P�_ V this reason
te:
CONSTRWION LENDING AGENC
I hereby affirm under penalty of perjury that there is a construction lending agency
work for which this permit is issued (Sec. 3097, Civ. C.).
Owner:
Lender's Name:
Lender's Address:
LQPERMIT
the performance of the
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Owner:
GREG HENRY
81640 RUSTIC CANYON]
LA QUINTA, CA 92253rD
(
i JUN 0 42014Contractor:
Owner CITY OF IA QUINTA
WORKER'S COMPENSATION DECLARATION
6/04/14
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
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,
070 that, if I should b dome subject to the rkers' compensation provisions of Section
/ he Labor Code, I Sh forthwith co I) with those provisions.
_pate: licant
WARNING: FAILURE TO SECURE WORKERS' CO NSATION COVERA E I UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTI AND CIVIL FINES UP 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 anypermit 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.
certify that I -have read this application and state that the above information is corr ct. I agree to comply with all
city and county ordinances and state laws relating to building onstruction, .and her by authorize representatives
of this cou y Vent upon the above-mentioned property r stn" 7 e .
Date. ;/ ignature (Applicant or Agent): �
LQPERMIT
Application.Number . . . . . 14-00000769
Permit . . . PLUMBING 2013
Additional desc .
Permit Fee 11.92 Plan Check Fee
.00
Issue Date . . . . Valuation . . .
0
Expiration Date 12/01/14
Qty Unit Charge Per
Extension
1.00 11.9200 LS PLBG GAS SYS, 1-4 OUTLETS
11.92
-----------.-----------------------------------------------------------------
Special Notes anis Coimuents
EXTEND EXISTING GAS LINE FOR BBQ 96" &
144" LN FT TOTAL OF 240 LN FT. 1/2 INCH
GAS LINE PER 2013 PLUMBING CODE.
=------------
---------------------------------------------------------------
Other Fees . . BLDG STDS ADMIN '(SB1473)
1.00
PERMIT ISSUANCE M/P/E
90.57
PLAN CHECK, PLUMBING
23.83
Fee summary Charged Paid Credited
Due
---------------------------------------------------------
Permit Fee Total 11.92 .00 .00
11-92
Plan Check Total .00 .00 .00
.00
Other Fee Total 115.40 .00 .00
115.40
Grand Total 127.32 .00 .00
127.32
4')
Bin #
Oty of La Qulnta
Building &r 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: g/Gytj tn�
Owner's Name:
A. P. Number:
Address:
Legal Description:
City, ST, Zip: �%ui,U{T. C.Ft
Contractor: i
_Telephone .)-/
Address:
Project Description: 46TX%w
City, ST, Zip:
Telephone:
:?•:<in;',N,.Ji:v�*'!'::;{';�Ffv''i:>l.i•':r:}i)y;ii%}:
:.::,.,:�•s:.;>;;::>:::>: �z>�;;�;;;.;;;f•.;•<:;s>
��
State Lic. # :
City Lie. #;
Arch., Engr., Designer:
Address:
City, ST, Zip:.
------------
Telephone:
<:<=v:<::s>;:<s:<::<:>>.
,.;;•><>•:,.: v:;_...,«::> .»» <
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
State Lic. #::
Name of Contact Person:Sq.
Ft:
#Stories:
# Units:
Telephone *,of Contact Person:
Estimated Value of Project: �!
APPLICANT: DO NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Recd
TRACKING
PERMIT FEES.
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cala.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
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.1.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Reyiew, ready for corrections/issue
Developer Impact Fee
Planning Approval
Galled Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Pcrmit Fces
I y
78-495 CALLE TAmpl'co
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
FAX (760) 777-7011
PROPERTY OWNER'S PACKAGE
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IWORTANT! -NOTICE TO rROPERT-YOWNER
Dear Property Owner
An application for a building I has b9on, submitted in your name lis if as the btvildeA of the property
improvemtentsspecified atM"I/ell -)AX
SW<: Wp� ..
We are p"Oviding.you with an Owner -Builder Ackmowledgmient.wid Information Verification Form to make you avmm of your
responsibilities and posuble risk you may -incur by having this permit issued in your name as the
Owner -Builder. We viii! not Issue a budding,permit until you have read, initialed your. understanding of eack'provkion,
signed, and returned this form to us at our official address indicated. An agent of the ovv= catwwVexecixte thivnotice
unless you, the property owner, obtain the prior approval of the permitting authority.
JJfY aii Ire4u6iit practice of unlicensed persons istohave -prope .0
ydwqerotiWit an "0wncr_,buil&?:
btilldingPciftuif that erroneously implies that the property owner is providinghisor tier own libor4fid maternal: personally "A
'As:
.an Owner -Budder, may be licid: liable and subject to serious financial, nsk:lor; any itijunes:sustained.b y, -an unlicensed porson
and his or her employees while worldng 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 insmance,coveragc for injuries to workers
0 y property -
y.
�2. 1 understand bui - Iding permits are not required to be signed by property owner's unless they are reiponsible for the
construction and are no * t hiring a licensed Contractor to assume this responsibility.
I understand as an "Owner-Builder"l am the responsible party of record on thePC=*I. I understand that I may protect
myself firom'tential financial risk by hiring licensed Con
PO tractor and haying the permit filed in his c.r her name instead of my
0
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed Contactors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, l.may be --onsidered an "employee'
under state and federal law.
M6_ I understand if I axn.considered an "employer" under state and federal taw, I must register with the state and federal
go-vernmenty--withhold-payroll-taxesI—provide-woikml-compe' tion-disability-insurance;--and-coutnbute-to-untmpleynient—
. nsa
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
M7. 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.
FkI uliderstand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable, for any
ma tal oc personal,:tt> acres Zustained by any subsequent owner(s) that result from any latent construction defects in the
Wr nanshi{i bi rna.tcrials.
9. 1 understand I may obtain re inf tion re ardin ni "bl'" aiions' is an "esti i{o cs" froru the Intctrml kc*, nue
y mo orma g g y. r& I Y
Service, the United States Small Business Administration, the:California Dcpartrncnt.of Benefit Payments' and die Galifocnia
Division of Industrial Accidents. I also understand I.may:contact.the Califoinia Contraciots':•State License Board (4CSLI3):at I-
800-321 -CSLB
-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party legal)y and pgncrally rvp=ible .for proposed c,,nstraction ac vity at the following address:in lzzlf -1
will abide by all
12_ I agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the >nfocmatiah 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 tkmse, 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 iwcivil corer. It is aho
important for you tounderstand that if an udicensed Contractor or employee of that individual or firm is injured while worlang
on your property: you maybe held. liable: for damages: if you obtain a ptrrnt
. 't. as Owe=l3uu1det and wish_ to hist Coatractora,
you will be respotssrble for veiifying wbcdw or icor tttosG Contractors arc pr'oprxiy lin ansoii and .the e,*tuS of their workers'
corupe=tion insuranoe coverage.
Before it building permit can be issued, this form must be compteted and signed by the property owner and returned to
the agency responsible for issu[ftg, ihc..permiL Nota: A copy of flte property owner's dsiver'>P lrcetrse+ farar +w iercOsay or
other veriiJication aecepiaMe to the agency is required to be presented when the permit. is saswd to verify the property
owner's signature.
i
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 for a construction permit for the Owner -Builder.
AUTHORIZATION OFAGFNTTO ACT ON >P)Ei.OPERTI' 4WNER'S..BEAAI�F
Excluding the Notice to'Property Owner, the execWon of which i undemand.is my personal responsibility, i hereby authorize
the followins Person(s) to act as my agent(s) 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 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 require to be pres ed when the permit is issued to verify the prope , owner's signature.
Property Owner's Signature: Date: t�O
CITYOF
FRA QUIN
TABUILDI4G
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& SAFETY DEPT.
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,VED
FOR CONSTRUCTION
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