10-1426 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 10-00001426
P-roperty-Address: x"52'7'0`0 AVENIDA RUBIO
APN: 773-283-025-13 -000000-
Application description: . PLUMBING
Property Zoning: COVE RESIDENTIAL
Application valuation: 100
T4ht 4 VOICE (760) 777-7012
FAX (760) 777-7011
BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 1/12/11
Owner:
FISHER CARL T. LIVING TRUST
PO BOX 408
PALM SPRINGS, CA 92263
Applicant: Architect or Engineer:
OGfi/�%fL
-----------------
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 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 hat 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 Contracto?s:State
License Law (Chapter 9 (commencing with Section 7060) 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 1$5001.: _
( ) L.as owner. of'the property, or my -employees with wages as their sole 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 oriinproves thereon,
and who does the work hirnself or herself through his"orher owrremployees, 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 theburden of proving that he or she did,not build or
improve for the purpose of sale.).
1 _ 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 I 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
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name: _
Lender's Address:
LQPERDi1•fIT
Contractor:
Owner
------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following, declarations:
_ 1 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,
and agree that, if I should become subject to the workers' compensation provisions of Section
3700 of the Labor Code, I shall forth 'th "comialw.with those provisions.
/Date: I . r ( A/PPlicant: ( _
WARNING:' FAILURE Td,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. r
1 . Eachpersonupon 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.
An a issued as.a result of this application becomes null and void if work is not commenced
within from date of issuance of such permit, or cessation of work for 180 days will subject
j,rj i I certify that I have tris application and state that the above information is correct. I agree to comply with all
J�11 cid a q my orfll
�� is and state laws relating to building construction, and hereby authorize representatives
1ohj� ° ~r y to e "port the above-mentioned property r in action
11 rpos
rl4r.� t idnature (Applicant or Agentl:
.... !415., a.._ II
LQPERAIIT
Application Number . . . . . 10-00001426
Permit . . . PLUMBING
Additional desc UNDERGROUND WATER & GAS PIPING
Permit Fee . . . . 42.00 Plan Check Fee
10.50
Issue Date . . . . Valuation . .
. 0
Expiration Date 7/11/11
Qty Unit.Charge Per
Extension
BASE FEE
15`.00
1.00 3.0000 EA PLB WATER INST/ALT/REP
3.00
3.00 3.00007.EA PLB GAS PIPE 1-4 OUTLETS9.00
1.-00: 15 0 0 0 0 --.EA PLB'-GAS?-METER .. ....
15.00
-
Special Notes and Comments
UNDERGROUND -•INSTALLATION.. -OF WATER &'GAS
PIPING PER `PLANS. 2007 'CODES..-
----- -------------------------------- --
Other.Fees . . . . . BLDG STDS ADMIN .(SB1473)
1.00
Fee summary Charged .Paid Credited
Due
Permit Fee Total .42.00 ..00 .00
42.00
Plan Check- Total 10-.. 50. .00 .00
1.0-.50
Other IFee Total .1.00. .TO 00:
1.00-
"- •,Grand Total 53.50 .00 00'
53.50
LQPERAIIT
P.O. Box 1504
LA QUINTA,_ CALIFORNIA 92247-1.504
78-495 CALLE.JAMPICO,
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
OPERTY OWNER'S PACKAGE
FAX (760) 777-7011
Disclosures & Forms,for Owner -Builders Applying for Construction Permits
VhW_M11"T! NOTICE10 PROPERTY OWNER
Dear Property Owner.
An. application for 'a - building permit has been ,submitted m ,your rismelisting yourself as the builder of the property
improvements specified at
We are providing you with. an: Owner -Builder Acknowledgment and information Verifieat.ion Form to make you aware of your
responsibilities and possrble'rislc you riiay incur by tiaVia this permit iss4e&in your name as "the
OwneF-Builder. We will not issue a building. permit untll`you°tiave 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.
statement below to -signify you erstand or ve fy tkis information.
"�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 �seiious. financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowner's insurance -r may not provide coverage for those
injuries. I am willfully acting as anOwner-Builder and am' ' aware of the `limits of my.insurance coverage for injuries to workers
on niy Party.
4 2. 1 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 Cdatrac6r to assume this responsibility.
3. I understand as an "Owner -Builder" I am .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.
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.
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.
/6. 1. understand if I am considered an "employee'' under state andIederal law, I must register with the state and federal
governmnt, -withhold payroll taxes; provide workers' compensation disability insurance; and contribute to unemployment
compensation for each "employee." I also understand my failure .to abide b.y.these laws may subject me to serious financial
risk
7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
structures cannot .legally build themwith the:intent to offer thein 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.
11 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, aypries sustained. by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
9. 1 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 (CS -LB) at I-
80/0-3
-
800-33 1-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
10. I that I am the
am aware of and consent to an Owner -Builder budding permit applied for in my same, and understand
party legally and financially responsible for proposed ' construction activity at the following address:
�l 1. 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 govem Owner -Builders as well as employers.
V11112. 1 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,. die 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 fain is injured while working
on your property, you may be ®dd. 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.permtL Note: A copy of the property, owner's dkker.'slibense form. notarization-, or
other verification acceptable to the agency is required to be presented when the permit is issued to rerify 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 for 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 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 hotarization,,or other verification
acceptable 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:
V 8. I understand asan Owner -Builder if I sell the property for which this permit is..issued, 1 may be held liable for any .
financial or person -` gtuies, sustained by any subsequent owners) thaVresult from any latent construction defects in the
workmanship or materials..
9. I understand I may obtain more information regarding my obligations as an' "employer' from the Internal Revehue-
Service, the Unitod States'Small Business Administration, the Calrforiva'Department of Benefit Payments, and. the California:
Division. of Industrial Accidents. I also understand I may. contactthe Cah oenia`Contractots' State License Board (CStB) at i-•
800-321-CSLB (2752) or www.cslb.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 legally and -financially responsible 'for` proposed construction activity at the following address:
agree that, as the party legally -And futaucially responsible for this, proposed • construction activity, i will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
12: 1 agree to notify the issuer of this form immediately of any additions; deletions, or &angel to any of the information I
have provided on this form. Licensed contractors are regulated by laws designed to- prgtect the public. If you contract with
someone who does not have a lkense,_the Contractors' .State Licease;Board.may be.%nabib to assist you with any financial loss
you may sustain as a result of a complaint. Your. only remedy "agamsr:unlrcensed Contractors, may be in.avil COWL It is also
important for. you to. understand iliac if an urtlioessed`Ccijatiactor• or;ea4ployce-of that individual or firm is injured while working
on your property; you maybe ht li"l for damages. Ifyou obtain,a; perm vas Owner-Ouildct and wisb to hire Contractors,
you wdl be responsibie for ver" or `riot those Contractors, are properly licensedand the status of their workers'
compensation intartauoe Coverage.
Before a building permit can be issued, this form must be completed"and signed by<t:he property owner and returned to
the agency responsible for'i suit tie"0ermiL Note: A cagy: of Ae P+up !'; 'S dm's fWW notankadon; or
other verification acceptable 'to eke agency, is required to lie pnese+iteit ,when die permit is issued to rer* the properly
owner's signature.
Signature of property owner ��1 4A ----.71K______1 Date; /
Note: The following Authorization Form is,regriired 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 AGENTTO:AGT-ON PROPERTY OWNCWS MH,
Excluding the Notice to. property owner, the execution of which1 understand:rs my, peooral'responsibility, I hereby authorize
the following persons) to act as my agent(s) 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 Authorised Agent:
Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the -address listed above and I personally filled out the abov
information and certify its accuracy. Note: A copy ofthe own er's"driver's license, form notarization, or.other verification
acceptable, to the agency is required to be presented when the permit is issried to verify the property owner's signature -
Property Owner's Signatuie: Date:
Bin #
City of La Qu►nta
Building & Safety Division
P.O. Box 1504,,78-495 Cale Tampico
La Quiki CA 92253 - (760)'777-7012 ,
i
Building Permit Appl►cation and Tracking -Sheet
Pennit #
J \b�
Project Address: Z
rJ %O� A vi=N 1 A 'I�� 3i.�
Y.
Owner sName' CA2i_ 1—► S1 = 2
A. P. Number. 3 _ Z -- G Z S
Address:s
a, b Ox Off'
Legal Description:�rZG / 13wW 1 G ' 'L % a 1 Z
City, ST, Zip: -p-AL-OA S (FEZ -i til S C 6,
Contractor: Qw N `ice
telephone:!.
Address:
Project; Description: vT-
0.I �- t.
City, ST, Zip:
Telephone; Y
State Lic. # : City Lic. C
_
Arch., Engr-, Designer (0 W fs iz4Z�
Address:
City, ST, Zip:
.
Telephone:
JIMCbmstruction
State Lic. #:
Name of Contact Petson:,2H 54 -ft
Type:. �F� Occupancy: ( 5 FIX_
'Project type (circle one):cw Add'n Alter Repair Demo
Sq. Ft
# Stories: .. ltk
# Units:
Telephone # of Contact Person: (( ` - �`%
Estimated Value of Project: 4t; p
APPLICANT:. DO NOT.WRITE BELOW THIS UNE
#
Submittal
'Req'd
Reed
TIKACKDVG
_ ', PERMrr FEES
Plan Sets
Plan Check submitted
P
Item Amount
Structural Cala.
Reviewed, ready for to.rreetions
Plan Check Deposit
Trow Coles.CaUed
Contact Penori,
PladCtieclk Balauu
Title 24 Gla.
:Plans picked up,
Coustraciiou
Flood plain plan
Plans resubmitted
Mechanlal
Grading plan
21' Review, ready .. for 6rrectio ue
'EletMeal
Subeoutactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.L.�
H.O.A. Approval
Plans'resubmitted
Grading
IN HOUSE:-
30 Review, ready -for eorrectlonsAssue
Developer Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. Appr
Date of permit Issue
School Fees
Total Permit Fees `ds�
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