09-0047 (DSF)4 P.O. BOX 1504 �VOICE 760 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 1/20/09
Application Number: 109-00000047 Owner:
Property Address: 53325 AVENIDA RUBIO AVENIDA RUBIO, LLC
APN: 774-072-015-4 -000000- 4607 LAKEVIEW CYN. #361
Application description: DEMO - COMML/OTHER WESTLAKE VILLAGE, -CA 91361
Property Zoning: COVE RESIDENTIAL ---=-----------
Application valuation: 0 (nj
a
Contractor: J�� f
Applicant: Architect or Engineer: Owner % 0 20i79
CITY OF Qt�047A
-----------------------------------------------------------------------------------------------
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 that I am exempt from the Contractor's State License Law for the
following reason ISec. 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 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):
(_) 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.).
( %4 1, as owner of the property, am exclusively contractingwith 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: �`' Z 0-O 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
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.
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 -.
37000 of the Labor Code, I shall. fort with cgmply with hose p visions.
q//►�'
Date: ` Z �V?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 (5100,000). 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.
T. 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 cou�enteruponbove-mentioned prope�rinspectio purposefete: pplicant or Agent):
Application Number . . . . . 09-00000047
Permit . . . DEMO PERMIT
Additional desc .
Permit Fee . . . . 45.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
0
Expiration Date 7/19/09
Qty Unit Charge Per •
Extension
BASE FEE
45.00
----------------------------------------------------------------------------
Special Notes and Comments
INTERIOR DEMO - DRYWALL, CABINETS,
PLUMBING, ELECTRICAL,
Fee summary Charged Paid
---------------------------
Credited
Due
----------
Permit Fee Total 45.00
----------
.00 ..00
----------
45.00
Plan Check Total .00
.00
.00
.00
Grand Total 45.00
.00
.00
45.00
LQPERMIT
Bin #
City of La Quinta .
Building U 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: 533 Z S 1/CK / 0L ai'. a b j '
Owner's Name: 4V n I L � C
A. P. Number:
Address:'
"1G0 7 L.//akGG�vi r
Legal Description:
Contractor: t( C r
/�3G
City, ST, Zip: W '�� G C4. &
Telephone: -G Z' 7 7 6
Address:
Project Description: e D
ro-
City, ST, Zip:
akft b f-ki
Qq� • nl
f
Telephone:
City Lic. #:
If 7
State Lic. # :
Demo
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
It Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: le67040. Q
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Redd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
Structural Cales.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
Zed Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Decd
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''d Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
�i
RECORDING REQUESTED BY:
NORTH AMERICAN TITLE CO
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DOC # 2008-0580579
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DEUTSCRE BANTi NATIONAL TRUST COMPANY, AS TRUSTRST'OR VnMT TRUST 2WS.FM MORTGAGE
PASS-THROMH CERTiFICATE%SERIES 20ft."S
hereby )m AVENIDA RU$IO LLC, A CALIFORNIA LIMITED LIABILITY COMPANY
the fallowing described rest popeny 1n the Cwmq of RIVERSIDE, State of CA1LWORNIA; C{Atg (J�
LOT 4 IN BLOCK 184 OF UDIIT 18 OF SANTA CARMIIdTA AT VALE LA QUINTA, IN THE C OF LA QUMA,
COUNTY OF RIVEBSLDE, STAxi OF CALwoRm& As pER MAp RECORDED IN BQOK 19, PAGE 31, OFMAPS, EN
THE OFFICE OF TBE COUNTY RECORDER OF RIVMSIDE COUNTY,
ALSO KNOWN A5`. SMS A VEMA RUBIO LA QUINTA, CA 92213
Date: Octoba 22.2008
SrATB OF PENNMV07AHOME
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MAMTAKSTA7EhC3N SAS DMECI80 ABOV_
State of California L
Secretary of State
`*<•raAp+° STATEMENT OF INFORMATION
(Limited Liability Company)
Filing Fee $20.00. If amendment, see instructions.
— READ INSTRUCTIONS BC -FORE COMPLETING THIS FORM
* FILED
in do ow Of ft e��.�ew�
dig mjB of state
1. LIMITED LIADJUTV COMPANY, MADE (Please m not rr manna is prep6nted.).
Avenida Rubio LLC
0 U 1 4 200$
DUE DATE:
This Space For Filing Use Only
FILE NUMBER AND STATE OR PLACE OF ORGANIZATION
2. SECRETARY OF STATE FILE NLUSER 3. STATE OR PL CE OF ORGM ZATM
200827410043 California
COMPLETE ADDRESSES FOR THE FOLLOWING po not ablyeviate ttie name of the d±y. Items 4 and 5 cannot be P.O. Boxes.)
4. STREET ADDRESS OF PRINCIPAL EXECLTTIYE OfFICF CRY AND STATE
4607 Lakeview Canyon, #361
ZIP CODE
Westlake Village
CA 91361
5. CALIFORNIA OFFICE bNiERS RZORDg ARE LIAtNTA1PIED (DOrAESTIC ONLY) CIT`(
4607 Lakeview Canyon, #361
STATE ZIP CODE
r- Westlake Village
CA 91361
NAME ANDCOfIf�LETE ADDRESS OF THE CHIEF EXECUTIVE OFFICER, IF ANY
B NAME ADDRESS CITY AND STATE
ZIP CODE
NAME AND COMPLETE ADDRESS OF ANY MANAGER OR MANAGERS, OR IF NONE HAVE BEEN APPOINTED OR EL
PROVIDE THE NAME AND ADDRESS OF EACH MEMBER (Attalfi additional pages, if necessary.)
7. NAME A!}DRE�$ CITY AND STATE
Martha J. Esterline 4607 Lakeview Can On, #361 ziP CODE
p Westlake Village CA 91361
E. NAME ADDRESS CITY AND STATE
ZIP CODE
9. NAME ADDRESS
- _ CrTY AND STATE IIP CODE
AGENT FOR SERVICE OF PROCESS (If the agent is an ir4ividuar, the agent m;at reside in California and Item 11
ZOOM. If the agent is a corporation, the agent must have on file with the Catitomia Secre moat be compteied with a California
1505 and Item 11
must be left blank.) tory of State a certificate pursuant to Corporations .node section
10. NAME OF AGENT FOR Sc-Ri/ICE OF PROCESS
Legalzoom.c om, Inc.
11. ADORES$ OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL CITY
STATE ZIP CODE
TYPE OF BUSINESS
12 DESCRIBE T11E TYPE O BUS ;\ESS OF THE L1NrTED LtABILI� COMPANY
Real estate
13. THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT.
Barbara Fisher
TYPE OR PRINT NAME OF PERSON COMPLETING THE PQM NA PURE
LLG•12 (REV MM)
n -A
Authorized Rep. 10/07/08
TITLE DATE
APPROVED 8Y SECRE'ARY OF STATE
TW�t 41 41-91914(raj
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAM PIC
0
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Formsfor •Owner=Builders Applying for Construction Permits
rAP0RT.4ArTt NOTICE TO PROPERTY OWNER
Derr 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 Y33ZS7e ,o( v r, .44, Q e
Weare providing you with an Owner Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the
OiAtLer-Builder. We will not issue a building permit until you have 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.
O""ER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIAt�'CTIONS: Read and initial eachstatement below to signify you understand or verify this information.
. 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. 1, as
an Owner -Builder, may be held liable and subject to. serious financial risk 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 -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my property.
Al2- I understand building permits are riot 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.
�i3. 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 Contra
own• ctor and having the permit filed in his or her name instead of my.
understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
• I understand if I employ or otherwise engage any persons, other than California licensed Contractors,
total valu
of my construction is at least five hundred dollars ($500), including labor and materials, I may be conssider ddan "employer"
under state and. federal law.
. [ understand if I am considered an'.employer" under state and federal law, I must register with the state and federal
government, withhold payroll taxes, 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.
understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
structeures cannot .legally build them with. the intent to offer them for sale, unless all work is performed by licensed
subcoyrtractors 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.
All- 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 injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
Or -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 (CSLB) at 1-
800-321-CSLB (27 52) or www.cslb.ca.gov for more information about licensed contractors.
16t0. 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:
�' 3 ZS ie 44a Cca.
/::4 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 govern Owner=Builders as 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 driver's license; 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. / 7 _ A /,
Signature of property owner Lu Date: / — Z t% — 0 Q
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($) 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 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..
Property Owner's Signature: Date: