BELC2016-0102T
78-495 CALLETAMPIC 44vO ,
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BELC2016-0102
Property Address: 54400 EISENHOWER DR
APN: 774253006
Application Description: FARROW / CHANGE OUT MAIN BREAKER
Property Zoning:
Application Valuation: $500.00
Applicant:
CARLOS A PENA
45829 MEADOW LAKE DR
INDIO, CA 92201
. 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.:
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
e
a alleged exemption. Any violation of Section 7031.5 by any applicant for a
jects the applicant to a civil penalty of not more than five hundred dollars
wner of the property, or my employees with wages as their sole
ion, 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 in nded or offered for sale. If, however, the building or improvement is sold
within a year of completion, the owner -builder will have the burden of proving that
she did not build or improve for the purpose of sale.).
I, as owner of the property, am exclusively contracting with licensed contractors
to constructhe project. (Sec. 7044, Business and Professions Code: The Contractors'
State Licyge Law does not apply to an owner of property who builds or improves
there o , and who contracts for the projects with a contractor(s) licensed pursuant to
,the ntractors' State License Law.).
C_
) I_am exempt under Sec. . B.&P.C. for this reason
L_
le Date, Owne
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 Name:
0
Lender's
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
STEPHEN FARROW
a
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i
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Contractor:
OWNER BUILDER
Llc. No.:
Dater 12/13/2016
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COW
0
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:
Carrie,._.Z Policy Number: _
I certify that in the performance of the work for which this permit is issued, I
s 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 w�i/th t se pro isions.
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, 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: Signature (Applicant or Agent):
Date: 12/13/2016
Application Number: BELC2016-0102
Owner:
Property Address: 54400 EISENHOWER DR
STEPHEN FARROW
APN: 774253006
Property Zoning:
Application Valuation: $500.00
Applicant:
Contractor:
CARLOS A PENA
OWNER BUILDER
45829 MEADOW LAKE DR
INDIO, CA 92201
t
------------------------------------------------,---------------------------------------------
Llc. No.:
Detail: ELECTRICAL - CHANGE OUT MAIN BREAKER. 2013 CALIFORNIA BUILDING CODES.
1 DESCRIPTION'
FINANCIAL INFORMATION
ACCOUNT QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306 0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:
$1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
OTHER ELECTRICAL EQUIPMENT
101-0000-42403
0
$25.33
DESCRIPTION
ACCOUNT
QTY
AMOUNT
OTHER ELECTRICAL EQUIPMENT PC
101-0000-42600
0
$2533
Total Paid for ELECTRICAL:
$50.66
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$96.27
Total Paid for PERMIT ISSUANCE:
$96.27
.,
Bin #
arty of La Qu«nta
Building 8i• Safety Division
Pennit ,'t 78-495 Calfe Tampico
La Quinta, CA 92253 - (760) 777-701,2
Building Permit. Application and Tracking Sheet
-Project Address: e p Jq6k /oW Owner's Name: BN u)
A. P. Number:
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Address:, r� �f(jp 4-vj
G/ 'c4., 4- 4L--�
Legal Description:
. City, ST, Zip:
Contractor:
o e.
P
Address:Project
Description: r/601
City' ST, Zip:
lA,=e / t' t� / •J �� ?.L K e e-AJ
e
Telephone:
P o e.
I
C C
State Lic. # :
City Lie.
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone: one:
Construction n TY aneY
Pe: Occupancy:
:
State Lic. .
Lc
ec t type (circle one • New Add'n Alter Repair.ar
It,Demo
0
Name of Contact Person:
f' /`-'Q'
Sq. Ft.:
# Stories:
#Units:
Telephone # of Contact Person: %&/b % %
Estimated Value of Project: 'SQO
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cafes.
Reviewed, ready for corrections
Plan Clieck Deposit
Truss Calcs.
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.
M.O.A. Approval
Plans resubmitted
Grading
IN ROUSE:-
'rd Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Aper
Dale of permit issue
School Fees,
.
I
Total Permit Fees
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT
78-495 CALLE TAMPICO (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
'S PACA
Disclosures & Forms for Owner -Builders Applying for Construction Permits
1"QR"T fN7"! NOTWIr. Td PROPIER , OWNER.
Dear Property Owner:
An application for a buildin t has been submi ed in your name listing yourself as the builder of the property
improvements specified at (j p d t d.
Z2 S'3
We are providing you with an Owner Builder A.cknowledgtnent and Info�tionV�ficantion Forni 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 Corm 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.
•�.,sx<•;J,a.�Yu: fcea[r arrQ;rnitrrtt etzGhsratNiirir�f bia owio. lio fy y1.
You undetictand..&r:verrfy tfio rnforntation.
� l l -understand a . requexrt p
building ractice of unlicensed Berson it to. have the property oyvner obtain an "Owner -Builder'
pert itthat crro�zeo;issly impties.tliat tire property o"r is providigg his , hers ur+m labor and' material peitsonally. I, as
an Owritr-liurldcr, may be held serious.frnancial risk for tory miluxics sustained by'an unlicensed
and his or her eriiployees while working on my property. My Inotncorvner`s itisuractce may -not provide
juries. I am willfully acting as an Owner -Builder and am aware
on my property. of the limits of my insurance coverage for injuries to workers
2:. I understand building permits are not required to be signed by property p rty owners unless they are responsible for the
construction and are not hiring a licensed Contractor to assume this responsibility.
3> I understand as an "Uwtzer-Builder" I am the responsibleparty
ntyxell frorti poteux nl financial ermit. I understand that I may protect
iWl y hiring a licensed Contract r a d hav g the permit fi din his or 1 er name instead of my
own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
Permits and contracts.
_W5..1undeistand.ifremgstoy or otherwise engage any persons, otherihan California licensed Contractors, and the total value
of my construction: is'at least five hundredldollars ($500), includirig:.lt boi and materials, I may be considered an "employer"
wider.state. and federal law,
6. I understand if I am considered an "employer' under state and federal law, I must register with the state and federal
tovernrtiient, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to uneanlrt.oyntent
tgayipcnsation for. each "employee." I also understand my failure to ab de by these laws :Wray subject rtne to serious iittancial
isle;'
. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
sirtictuitr�- c,i»aaot ntial
legally Guild t3ionn rvitli the nteIli t"o offer them for sale, unless all work is perforrired byeliceensed
subcontractors and tJnC nurrilner. of structures does,.raot exceed four within any calendar year, or all of the work is performed
and r vontrao lvitli.a licensed genaml.building Contractor,
$, I undcrsttnd as as Otvncr-B'uilcict if I sell tiieptpperty for which tris permit is issued, I may be held liable for an
W10*cial ors iat irijaiie"s sustained by any subsequent owners) that result from any latent construction defects in the
wtar�,`iiiaxislnin or tt�atcrials. .
9• I utidcrsratI6 I may obtain more inforittatian regarding.
S- xvice, the 1Jniteci States Small Business dUunistiatio, the alif California Department of Benefit Paymendbligationsas an "employer" from ts,Internal Revenue
andthe California
'Division of lndtistrial<Acddents. I also understand I ntaay contact the California Contractors' State License Board (CSLB) at 1 -
Ca
800- (27$2) or www.cslb.ca.gov for more information about licensed contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party:legall, and' financially . responsible for - .proposed - construction activity , at, fr-the following -address:
��� , �' � � w
�l,t ,I agree that, as tifo
partylegally and financially responsible for this proposed construction activity, I will'abide b all
applicable laws and requitbmeri#a that govern�`OGvtier:Iigilders as.wel2 as employers, y
cc
cJ l 2. I' agree to. uotify,thc rstlier Of this farm .irmxtediiateily of any additionsi delet diiS, or changes to any of the infozntation:I
have provided on flus #bran <iicensed corittactbrs aae.xegulated by laws designed to protect the public,: It`yeit. contract with
someone who docs not tt9Vi3 a 11Zc Esse, tltc:tCntractgrs' State ticcnsc Board maybe unable to assist you with; ariy fln=ial. loss
you may sbstaih as a rtsitlt of a complaint. Your only romedy against UWioensed Contracts rs. iniiy 'be,in civil oourt.-itis t►fso
important for ydec to iivdcrsttrnd fhat:if an unlicensed Contractor or er>Ypioyee ofttiat uidividual or f.,irixi is:ii jureii while worlsiitg
on your property, You may be,Iieid liable f6r damages. If you obtain a penmit'as::0um=Builder and. wisZ.to true Cdatractors,
you v✓n ti responsible for rage, a9 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 respanstlsle fat issuing the permit, Note: A copy of the.propeny owner's driver'sWeens
Other I ileal(Ott acceptable to the agency � o verify y #ie atiax, or'
g y is required to be. presettteif when the permit is tssurd to verify ffie property
awe+er's signature:
Signature of property owner 4-2 EeMn AX Date:
Ti 9
Note: The following.4uthori=tion Form is required to be completed by fhe,prope)ty owner only when designating
an agent of the property owner to apply for a construction permil for the Owne m -Builder
". + vi:n� i 1..lJ.R�.;..� VrV..i KtJl'#�iJc`•7;� . ♦'i L• L4��7 ..L7EHAL1`
Excluding the Nolicc to Property a. er, the e7ieeutipn cif y hIM I understand is my personal responsibility, thereby authorise
the followingpen to aci as my agents) to apply for, sign, and file the documents necessary to obtain an Owner -Builder
Permit for mypt.,ojoet:
Scope of Construction Project (or Description of work);
Project Location or Address:. ILI 7�
Name ofAtifhoriied Agent•���
T�� � � ��
------ ---- el No, . , (� ,?
Address of Authorized Agent.
.............
ce, .
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; -,4 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' sued. to verify the property owner's signature.
Property O.wrier's Signature; ��, � •
Date:~�f'�p