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12-1428 (PLBG)P.O. BOX 1504 78-495 CALLE TAMPICO „ LA QUINTA, CALIFORNIA 92253 T&f uIK,iGv --.�1 VOICE (760) 777-7012 FAX (760) 777-7011 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Owner: VELASCO RAUL 51970 AVENIDA VELASCO LA QUINTA, CA 92253 ( Contractor: Owner Date: 12/12/12 Q a 2.2011 CITY OF FIIuAhI —- -------------------------------------------------------------- LICENSED CONTRACTOR'S DECLARATION - WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations: Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided License Class: License No.: for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Date: Contractor: _ 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 workerscompensation OWNER -BUILDER DECLARATION insurance carrier and policy number are: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the Carrier - - - - - - - - - - - - - - - - - - - - - - - Policy Number following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to _ I certify that, in the performance of the work for which this permit is issued, I shall not employ any construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the person in any manner so as to become subject to the workers' compensation laws of California, permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State and agree that, if I should become subject to the workers' compensation provisions of Section License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the Labor Code, I shall forthwith comply with those provisions. 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 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.). (_ 11, 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.). ( ) I am exempt under Sec. , B.&P.C. for this reason Date:_ 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 Name: Lender's Address: LQPERMIT Date: - Applicant: J 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 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 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 county to enter upon the above-mentioned property for inspection purposes. Date: - Signature (Applicant or Agent): LQPERMIT Application Number. . . . 12-00001428 Permit PLUMBING SEWER Additional desc . Permit Fee 30.00 Plan Check Fee .00 Issue Date Valuation 2500 Expiration Date 6/10/13 Qty .Unit Charge Per Extension BASE FEE 15.00 1.00 15.0000 EA PLB BUILDING SEWER 15.00 Special Notes and Comments SEWER CONNECTION SEPTIC ABANDONMENT. Other Fees BLDG STDS ADMIN'(SB1473) 1.00 Fee summary Charged Paid- Credited -Due Permit Fee Total 30.00 .00 .00 30.00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 31.00' .00 .00. - 31.00 LQPERMIT COACHELLA VALLEY WATER DISTRICT 37RtiO� P.O.-BOX 1058,.COACHELLA, CALIFORNIA 92236 (760) 398-2651 INVOICE Date: 12/12/2012:- SUBJECT: 2/12/2012 -SUBJECT: SANTA CARMELITA, 51970 AVENIDA RUBIO, LA'QUINTA,'LID 682190, "SCC FEE ONLY" RAUL VELASCO Project: 12-4273 51970 AVENI:DA RUBIO Project Date: ' ;:12/12/2012 1 Amount Due: $4;231'.00 LA QUINTA, CA, 92253: GEO* 06-0.6-0.1-3 Planner: ' SANDRA VILLALOBOS TO INSURE PROPER CREDIT, PLEASE RETURN THIS PORTION WITH REMITTANCE AND INCLUDE THE PROJECT ON YOUR CHECK COACHELLA VALLEY WATER DISTRICT P.O. 9OX_1058,:C6ACHELLA,,CALIFORNIA:92236 (760) 398=2651 s Page _1 PV P` ✓ %L - 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 [item npmpVl'NI g Dear Pneperty Owner. An. application for a building permit has been submitted in nmptovera nts RM &W at Your name listing yourself as the builder of the prop" aru Pow You w an Owner -Builder AclmowledVDMtand la%rmatien Ver�eation Form to make you awam of your des and possible risk You May incur, by hrivirrg this m. in your name as the Owncr-B+iidder. We va stot issue a building Per" until Yui lave read, iiia led your understanding of eadr previden, signed, aad returned this form to us at our ofdidal address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. AA'N 4)� II�Q�7:N DffdXTfOl11s. Read a vrmcr! earls mutnrerrt*eteW m s< g�rijy you er�rderstand or very dies irtJornration. 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" building permit that erronoously implies drat 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 unlit peen 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 iusurance coverage for injuries to workers on my property. ;72- 1 understand build' Permits nig Pe is 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. 'Z3. I understand as an "Owner -Builder' I am the responsible party of record on thet. 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. A' ✓�l4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. Ri• ✓X. 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. ' understand if I am considered an -employee, under state and federal law, d must register with the stale and feden government, withhold payroll taxes, provide woikers' compensation disability insurance, and contribute to unemploymel compensation for each "employee." I also undbrstand my failure to abide by these laws may subject me to serious fmanci ' /risk. P' V I understand under California Contractors' State License Law, an Owner -Builder who builds single-family resident - structure's cannot legally build them with the intent to offer them for sale unless all work is performed by licens subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perform under contract with a licensed general building Contractor. I,. V V V )''V IL 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, 1 may be held liable for any financial or personal mouses sawed by any subsequent owners) that result from any latent construction defects. in the rcrvL y obtain more information regarding my obligations as an "employee' from the b*creai Renenua 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 TSM at l - 8-3�.1-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. 7/10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the part' legally and financially raTonsible for proposed construction activity at the following address: nn � _:/_l I . I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all I� 712 ble laws and roquireutents that govern Owner -Builders as well as employers. . ( to notify the issuer thi to am of the information I agree fY of s form rmrnedtately of any addnttotts; doktsans, or changes y have provided on this form Licensed contractors are regulatod by laws designed to protect the public. If you contract with someone who does not have a lieaase, the Contractors' State Licence Board may be unable to assist you with any fina inial loss YOU may sustain as a result of a complainL Your only remedy against unlicensed Contractors MAY bee irt'civil c L It is also imptxtam for you to understand that if an trwkaww Contractor of esavloyee of that individual or turn is iejurod wbivc Working on your property. you may be held liable for damages. If you obtain a permit as Owns -Budder card WWI to hire colors, you will be reWo=A& for verdying whether or not those Conunctora are prepeft tieeosed and the status of their workers' coanpesasstkm insurance ooverage. Before a budding permit can be issued, this form must be completed and signed by the property owner rued returned to the agency respoesMe for issuima:lhe permit. Now A copy of skv properV owner's e1}ivWx from "WkOOM er other verification aseep$We to dee agency is mquired to be presetrted when doe permit is i"WJ w My due prVeM owner's signature. d l Signature of property owner � w- [� �r7 Date —1 Z Note: Tire 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 BIEHAL•F Excluding the Notice to Property Owner, the exm ution of which I understand is my personal responsn`bihty, I hereby authorize the following peraon(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 �kuthorizod 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 ab' information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification aoceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Bin.# Clay 0 Ld Qulhtd Building 8i 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: 97o Aw Owner's Name: . C-' A. P. Number. - Address: . Il/ El SAE Legal Description: Contractor. City, ST, Zip: Telephone:' „:�. sY. >sa Address: %� Project Description: City, ST, Zip: L(/�ylrt.T/fi -- Co A/ (\J,(-. G Telephone: % 2 — l6 "3 �1 `' �i R�''f '? �7.�R< City Lic. 9. State Lic. # : Arch., Engr., Designer Address: City., ST, Zip: Telephone: State Lic. #: r ;w;° Construction Type:. Occupancy: Project type (circle one): New Add'n Alter Repair Demo Sq. Ft.-. #Stories: # Units: Name of Contact Person: Telephone # of Contact Person: Estimated Value of Project • 5&0--C APPLICANT: DO NOT WRITE BELOW THIS UNE N Submittal Req'd Recd TRACMG PERMITFEES- Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit. . Tress C21ce• Called Contact Person Plan Check Balance. Title 24 Cales. Plans picked up Construction Flood plain plan Plans resubmitted.. Mechanical Grading plan Z'' Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Graut Deed Pians picked up ML H.O.A. Approval Plans resubmitted Grading IN HOUSE:- ''" Review; ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees