10-0259 (BLCK)f
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
�
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number:
4:Z_0 = 0 0_0.0.0.2.5-9>
Owner:
Property Address:
52720 AVENIDA RUBIO
LOPEZ DORA
nnR
APN:
773-313-001-26 -000000-
52-720 AVENI
R BI��`"
Application description:
Property Zoning:
WALL/FENCE
COVE RESIDENTIAL
LA. QUINTA, CA
( 2095OF�
2 53
Application valuation:
3031
VOICE (760) 777-7012
FAX (760) 777-7011
il�TIONS (760) 777-7153
IDate: 3/26/10
ntractor• '
-- Applicant: / Architect or Engineer: Owner
I&I
UCENSEO CONTRACTOR'S DECLARATION - WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury than em licensed under provisioris-ofChapter 9 (commencing -With I hereby affirm under penalty of perjury one of .the following declaratioris'`'
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 LaborCode, for the performance of tfie 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; f6rthe performance. of the work for which.tfiis-permit is issued. My 'workers' compensation
"OWNER -BUILDER ' DECLARATION insurance carrier and.policy number are;
hereby affirm unde.r,penalty of perjury that am,e.xemptfrom the Contractor's State License Law for the •, Carrier -'- - - - - - _ - = --- - - ---
- - -.r Policy Number -
.following reason (Sec. -7031.5, Business andProfessionsCode: Any city or county that requires a permit to _ I certify that, in the performance of the work1for 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,
perrnit to file a.signed statement thathe or she is licensed pursuant to the provisi6ns 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 comp) with those provisions.
thatihe,or sheds exempt therefrom and -the basis for,the alleged exemption. Any violation of -Section 7031.5 by -� / n - ��
any pljcantfor a permrtaubjects,the'applicant toacivippenalty of not more than fivehundred.dollars (55001.: Date-'C�(�—IVP,ppli` can C621
(. I, as ownerof theproperty, or my employees with;wages,as their sole compensation will.do the work, and _ -
the structureis not intended or offered. for sale (Sec. 7044, Business and Professions Code:...The WARNING:. FAILURE TO SECURE WORKERS' COMPENSATIONCOVERAGE IS UNLAWFUL, AND -SHALL .
Contractors' State Licerise.Law does"- apply,to,an.owner of property who,b',uilds 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 ($100,000). IN ADDITION TO 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 ATTORNEY'S FEES. '
9d year of;completion the owner builder will have the burden of'proving that he or she'did not build or t
improve for -the purpoie,of sale.): • • - ' .APPLICANT ACKNOWLEDGEMENT -
(_) I, as owner'ofthe.property; am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building and Safety for a-permitsubject to the
7044,. Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractors) licensed. 1. Each person upon whose behalf this application is made, each personat whose request and for -
Pursuant to the Contractors' State License Law.). whose benefit work is performed under or pursuant to any permit issued as a result of this application,
(_ 1 I -am exempt under Sec. - , B.&P.C. for this reason the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Ouinta, its officers, agents and employees. for any act or omission related to the work being
performed under or following issuance of this permit.
Dai to: -3' '�w r -Owner;— 0 � /�"t ipi 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
CONSTRUCTION LENDING AGENC permit to cancellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the 'I certify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.). city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned prope for inspection purposes.
Lender's Name: �/] �G
Date:J22, �7Signature (Applicant or -Agent): / `" z �`' / lJyoe—'
Lender's Address:'--
LQPERMIT
f
Application Number . . . 10-00000259
Permit . . . WALL/FENCE PERMIT
Additional desc .
Permit Fee . . . . 63.00 Plan Check
Fee
.00
Issue Date . . . . Valuation
. . .
. 3031
Expiration Date 9/22/10
Qty Unit Charge Per
Extension
BASE FEE
45.00
2.00 9.0000 THOU BLDG 2,001-25,000
18.00
----------------------------------------------------------------------------
Special Notes and Comments
140 LN FT X 5 FT HT BLOCK WALL PER CITY
----------- - ---------- STANDARDS -&-APPROVED PLANS.--'PRIOR'PERMIT
_......
- - -
#05-0708 EXPIRED.
----------------------------------------------------------------------------
Other Fees . . . . . . . BLDG STDS 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
Grand Total 64.00 .00
.00
64.00
LQPERMIT
P.O. BOX 1.504
LA QUINTA" CALIFORNIA 92247-1,504
78-495 CACLETAmpic'o
LA QUINTA, CALIFORNIA 91253
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
PROPERTY OWNER'S ,PAC:
GE
FAX (760) 777-7011
Disclosures & Foirins for: Owiier=Buiilders Applying for Constrd ction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER.
-Dear Property Owner.
An. application for a building permit has been submitted in your name listing, yourself as the builder of the property
improvements specified -at.
Weare providing YOU with an-Owner.-ouilder-,Acknowledgment -and-Iiiformatioil;Verificati6ii-Fdrm to make you aware of your
responsibilities and possible n. y incurby�having.:this permit isstied-iii.your';n'am'eas,;the.
Owner -Builder. We will not issue -a
ding:pe.mit until, iyqu.. have read initialed your understanding of each provision,
signed, and returned this form to us at our OlTi I c ial address'indicated. An agent Of the: owner cannot execute this -notice
unless you, the property owner, obtain theprior approval of thep
"iting authority.
sign'6�.oduniiderisltan 'or' -v` thii injormation.
DIRECTIONS: Read,and.�iniilial 'ea�hsia.temeht below d er*
]. I understand a frequent. practice of unlicensed persons- is ,to, have the property - owne . r obtain an "Owner -Builder"
building permitthat errondously;uTplies that the prop
-erty. own-er; is.'providing his or her bwn'labor and material personally. 1, as
an Owner -Builder, may be held liable and subject to sehoim financial. risk for any injuries sustained by an unlicensed person
and his or her employees while working .. My homeowner's insurance may. not provide coverage for those
g on my property,.
injuries. I am willfully acting as an Owner -'Builder and am aware of the limits of my insurance coverage for injuries to workers
on. my property.
�)_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 alicensed Contractor to assume this responsibility.
,LI I understand as an Owner -Budder"' I am theresponsibli.par 'ty of record on the perriiit.; I understand that I may protect
e
u-mg tonti�c an having the p eirmit filed in his or her name instead of my
myself from potential financial risk b 1 hi J licensed tor d
y -a ic
own.
t4. 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. 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 in . ay be considered an "employer"
under state and federal law.
�Y_6. 1 understand if I am considered an"'eniployee Under state,.aqd federal law, federal
must register with the state and fe eral
government, withhold payroll taxes; provide workers' compensation �disii�iiiiy' iniuiaiic e, and'
rid contribute . te to unemployment
TPP
compensation for each"employee'' [' also undersiafid my.tilure to abide by 'these laws may subject me to serious financial
risk.
_�(7. 1 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.
\*. 8_ I understand as an Owner -Builder if h:sell the property for which this permit is issued, I may be held liable for any
financial or personal. injuries sustained by any subsequent owner(s) that -result 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 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 1-
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:
11. 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 govern Owner-Buildersas well as employers.
12. I 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, 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 in civil court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working
on your property; you may be held 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 permit. Note: A copy of the property owner's deiver's-Utense; form notarization, or
other verification acceptable to the agency is required to be .presented when the permit is issued to verify the property
owner's signature. A
Signature of property owner Date: —� u
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, l heieby authorize
the following person(s) to act as, my agents) to apply for, sign, and file the documents necessary -to obtain an Owner-Buildet
Permit for myproject.
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 notariiation, 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:
Site. Requirements for:
Corner. Lot
(E-EZampl - B)
SIDE .=_ ST
ee
SIDE YARD; 10 Feet
Minimum .
Minimum
REAR --YARD:
10 Feet Midiml
FR ON'P YARD; .�
20 Feet Minimum
'URB LIME
)PERTY LWES
Bin #
City. of LaQuinta
Building 8r Safety'Divislon .
P.O. Box 1504, 78-495; Calle ;Tampico
La Qulnta,,CA 92253 -,•(760)'777-7012
Bdild pg Permit.,, cation and Tracking Sheet
'
Permit #
Project Address:
.Owner's Name: rG LoG Z
A. P. Number:
Address: 5.0--72-c-) Ave U
r
Legal Description:.
Contractor:
City, ST, Zip: Q Oct /-4 -ILA4<=A Z zs-
Telephone :
Address:
Project Description:
City, ST, Zip:
Telephone:2,a:�:
City Lic. #:
L. G W
State Lic. # :
Ul. dY
Arch.,. Engr., Designer:
,L% 12 A—, -L . C_er t o .
Address:
City., ST, Zip: .
Telephone:
State Lic.
iii:%}:C� )hijjtv:�,T••'. .. hl ��+
Construction Type- 3l Occupancy:
-. •
Project type circle one New .; Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
#Stories:
#Units:
Telephone # of Contact Person:
Estimated.Value of Project:
APPLICANT: DO .NOT. WRITE BELOW THIS LINE
#.
Submittal
Plan Sets
Req'd
Rec,':d ti
TRACKING
Plan Check submitted
PERMIT FEES
Item Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
PIan;Check Balance.
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2''. Review, ready for correctionstissue
Electrical
Subcontactor List
Called. Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted .
Grading
IN HOUSE:-
34 Review, ready for correctionstissue
Developer Impact Fee
Planning Approval
Called Contact -Person
A.I.P.P.
Pub. Wks. Appr
Date of permit'.issue
School Fees
Total Permit Fees