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12-1475 (BLCK)4 P.O: BOX 1504 VOICE (760) 777-7012 78-495 CALLE TAMPICO ,e FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT ' INSPECTIONS (760) 777-7153, BUILDING PERMIT Date: 12/21/12 Application Number: X12=00001475 Owner: Property Address: 52715 AVENIDA RUBIO DAVID MEEKS APN: .773-282-024-11 -000000- 52110 AVENIDA MONTEZUMA Application description: WALL/FENCE LA QUINTA, CA 92253 Property Zoning: COVE RESIDENTIAL --------------------------------- Application Valuation: 3197 < Contractor: + Applicant: Architect or Engineer: Owner D /1 a ----------------- --------------f'_.�-j LQIZ CITY OF'LA QUINTA' FINANCE DEPT. ----------•----------------------------------------- ------ LICENSED CONTRACTOR'S DECLARATION - ViORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of. perjury that I am licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjuryoneof the following declarations: ' Section 7000) of Division 3.of the Business and Professionals Code, and my License is in full force and'effect. _ I haJe,and'will maintain a cenificate of consent to self-irisure for workers' compensation, as provided License Class: License No. - - - forty -Section 3700 of the Labor Code, for the performance of the work for which this permit is = issued: .. Date`. Contractor: _ I have andwill maintain workers' compensation insurance,. as: required by Section 3700 of the Labor - Co e,.forthe performance of the work for which this=pe`rmit is issued. My, workers' compensation OWNER -BUILDER DECLARATION insurance carrier•and policy number are: I hereby affirm under penalty of perjury -that I am exempt from thejContracto 's State . License Law for. the 'Carrier t Policy Number ,f following'reason (Sec: 7031 .5, Business and Professions Code:,Any city, or county that requires a permit to Lcertdythat, in the performance -of the work for which this'permicis 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 3hat;.if.l should become subject to the workers' compensation provisions of Sectio_ n .License Law '(Chapteri9,(commencing•witti Section X70001 of Oivisicn'3'of the Business and,Professions Code) or 3700 oUthe'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 ` n applicant for a permit subjects the applicant to'a civil penalty of not more than five hundred dollars 1$500):: Da �� '�--A cant: `�-•� '1� (r, .1. : tel'\ ° ... ) l 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 .WARNING: FAILURE TO'SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL Contractors' State License taw does not apply to an owner of,property who builds or improves thereon, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND •and who does the work himself or herself through his or.her own employees, provided that the - .DOLLARS ($106,000).. INADDITIONTO THE.COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN improvements are not intended or offered for•sale. If, however, the building. or improvement is sold within 'SECTION 3706 OF THE LABOR CODE; INTEREST, 'AND ATTORNE_ Y'SFEEs. - one yearof,completion,*the owner -builder will have the burden of provirig that he or she did not build or 'improve.for the purpose of sale.).- �� .;. •APPLICANT ACKNOWLEDGEMENT 1 _ 1 1, as owner of the property,`arti exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions Code: TheCbntractors' 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—) I am exempt under -Sec. B.&P.C. for this reason �7/� caner: CONSTRUCTION LENDING AGENCY 1 hereby affirm under penalty of perjury that there is aconstruction 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 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. Ariypermit 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 'ss county to enter upon the above-mentioned projp�ertty f".j p\ection purp ses. Date/-?-' ,gnature (Applicant or Agent):(:f - o Application Number 12-00001475 Permit .'. . WALL/FENCE PERMIT. Additional desc . Permit Fee . . . . 63.00 Plan Check Fee .00 Issue Date . . . . Valuation 3197 Expiration Date 6/19/13 Qty Unit Charge Per _ Extension BASE FEE 45.00 2.00 9.0000 THOU BLDG 2,0.01-25,000 18.00 --------------------------------------------------------------------- Special Notes and Comments G GARDEN . WALL' ;" TOTALING` 13 5 .<.L': F . , '82 LF a 1-,& 5.3 LF @ 5' , CITY "STANDARD. 2010 CODES... ----------------------------------- OtherFees BLDG SIDS ADMIN (SB1473) 1.00 .Fee'summary Charged,,- Paid Credited Due. Permit Fee Total 63.00 .00-. 00 63.00.. Plan Check Total 00•'. .00 00 .00 Other Fee Total 1.00- .00 .00' 1.00. Gr"and'.;Total 64.00 00 ..00' 64.00 " N• < _ LQPERMIT 0• P.O•. BOX 1504 LA QUINTA, CALIFORNIA 92247-1504 78=495 CALLE TAMPICO: LA QUINTA, CALIFORNIA -92253 PRO PERTY "O WNER' S PACKAGE BUILDING & SAFETY DEPARTMENT (760) 777-7012 FAX (760) 777-7011 Disclosures &' FOrms for Owner Benders Applying' e Construction Permits .E'4M2A!YT! NO -111 F Tn RQPTiLTY nWNI�R Dear Pity Owner Aa. ap)ication .for a- biuldrug p"=' 'has b'em-, bvbmitted in your _name listing . yourself as the builder of the . property inaprovemeatsspecified ai am- I'0viyou art Owner-@ulide< AcknawleE and [ufofmatien Verifieativn.Fortn to,make you awa>,a of your r+evensi iWies and possible tisk }iou may recur by l evo peiribm"t.issiW, In roar nam$ as:the Owner=BuMer. We wol.sot issue a butt ' ` ; d permit ilnt. pv�i: tiave head, inittiEiW yQiix: n$derstand� of each provision, signedl,.aad returned this form to us at oitr„offdil address iadtcated. An.agent of the owner cannot execute this notice unless you, the Property owner, obtain theprior approval ofthe permitting authority. L1.Q�!rriAf.C� Ri^!iI1V.�i+�.� ..... ��.—. _. _ _ ... . - .+•. ... . - - ....,... - RBRI� R/lEf'&rftidi each: Stute7JiPi[I X 036 lb S< OU inrderstand `;o gn6 y verify rtiis iirformaaion. r I understand a..frequent practice.'of unlicensed- persons is, to have the property' owner obtain an "Owner -Builder” building permit that q'oneously implies that the property owner is providing his or:her. own labor and material personally. 1, as an Owner -Builder, ruay be held liable and subject to serious'finaneiafiisk 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 -guilder and am aware of the limits of my insurance coverage for injuries to workers on my property. 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_• 3. I understand as an "Owner -Builder" Iam the responsible, party of i�cord.on the pe -1 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. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. . 5.1 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: .I: understand'.if I am considered an "employer .under state and federal law, i must register with the state and federal government, withhold payroll takes, ;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. ' k- 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 performer under contract with a licensed general building Contractor. v 8. 1 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. io cies wstaked by any subsequent owners) that result from any latent construction defects in the worlmnanship or materials. 9. I understand I may obtain more information regarding my obligations as an "employee' from the' IaRerml 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 (CSLI3) at 1- �8-0-0-3321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the ply legally and financially responsible for proposed construction activity at the following address: agree that, as the party legally and finaacially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well ag employers. ,,_r,2. I agree to notify the issuer of this form immediately of any additions, deletions, or ch*nges to *my of the information I have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with somoone who does not have a beense, the Contractors' State License Board may be unable to assist you with 88y 6ruanaial loss you may sustain as a result of a complainL Your only remedy against unlicensed Contractors may be in%civil court. It is also impOrtamt for you to understand that if an uryfioensod Contractor of employee of that individual or firm is k4u'od while woddng on your property, you may be held hable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you wdl be responsrbla for verifS,ing Wiw&w or not those Contractors are prWedy licensed and the status of fim wotkers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner aad returned to the agency responsible for issue; dw.permkL Now A copy of dic proper* owner's ewer's fevan 19ta*10"h"4 or other verification acceptable to the agency is required to be presented when the pemdt is itrued to rt►(f!' the MvpeM owner's signature. Signature of property owner/-�v�-�/�% 6 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 BFHAUF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I herebY authorize dhe following persons) to act as my agents) 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 abov4 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 required to be preserted when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Bin. # r . city of La Qurnta Buifding'ST Safety Division;, , .O Box S0.4,78 495 Cafe Tampico La:Qulnta, EA'92253 - {760} 777-7012 Burldrn Permrt<Applicatton: and Tracking. Sheet g Permit# Project Address: S' Ownu's Name •1 Address:. ' Legal Description: City„ST, Zip: SJ' Contractor, ..Telephone: - ,:, zl-•” s I Address:_Project.Descriptio "+ � Gla,/ /3S' City, ST, Zip: ` Telephone: f� 3. iq .5.1 State Lic. # : ;Ci•Lic'. Oz ry Arch., Engr., Designer Address: City., ST, Zip:' Telephone:1 mow.. State Lic. #: f ' :. o .... �`%i>rb Name -of Contact Person: "Corin on Type, Occupancy: Pio ecY circle one 'New Add'n Alter Repair Demo 1, tyle= ): eP Sq. FL: #;Stories: #Units: Telephone # of Contact;Person: - Estimated Value of Project APPLICANT DO;NOT WRITE'BELOW:THIS UNE - N Submittal Req'd Redd TRACMG, . ?PERMIT FEES Plan Sets ?P1 Check sabmitted Item Amount Structural Calm Reviewed, ready for corrections.. Plan Chcck•Deposit. . Truss Coles• Called Contact Person Plea Check Salaace Title 24 Calci. Pians picked up'',. _, Construction Flood plaln plan Tlans resubmitted- - Mechanical Grading plan. r! Review,ready-CorrnrrecGpnsfisst e . ' Electrica4 Subeontaetor fist Called Contact Person Plumbing ` Grant Deed Plans'pickedup �S.M.L ' H.O.A. Approval Plans resdbmitted Grading v ' IN HOUSE:- 7i° Review; ready for correctionsAssuc Developer Impact Fee Planning Approval Called ContactPerson`, A.LP.E Pub. Wks. Appr Date of permitissue School Fees ' Total Permit Fees