10-0015 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: r_10-00000015
Property Address:
53485 AVENIDA RUBIO
APN:
774-072-021-11 -000000-
Application description:
WALL/FENCE
Property Zoning:
COVE RESIDENTIAL
Application valuation:
1719
T-vy 4 4 Q"
Applicant: / Architect or Engineer:
' v
BUILDING &SAFETY DEPARTMENT
BUILDING PERMIT
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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 (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 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 pplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 155001.:
( �) 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.).
(_ 1 I, 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—) I am exempt under Sec. , B.&P.C. for this reason
f-Date•,r ,o ,, �Ovin&e r CA, :A0.[/tit`,
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
Owner:
RAIM L. MARTHA
53485 AVENIDA I
LA QUINTA, CA S
(
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
1/06/10
-----------------------------------------------
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.
_ 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, 1 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 forthwith comp, with ose provisions.
0
-Date:- � .,,,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 1$100,0001. 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 pfor inspecti in purpose
Date: • to Signature IA pplicanYor..Agentl: �.
J
Application Number 10-00000015
Permit WALL/FENCE PERMIT
Additional desc .
Permit Fee . . . . 41.00 Plan Check
Fee
00
Issue Date . . . . Valuation
. . .
. 1719
Expiration Date 7/05/10
Qty Unit Charge Per
Extension
BASE FEE
15.00
13.00 2.0000 HND BLDG 501-2,000
26.00
- ------------------------------------------------ -------------------------------
Special Notes and Comments
35 LN FT X 6 FT HT GARDEN BLOCK WALL;39
----_--..._--------.--_..-- ------ ..-•-...--...__
IN FT X 5 FT HT GARDEN BLOCK WALL PER
CITY STANDARDS & APPROVED PLANS. (1)
WROUGHT IRON GATE 4FT X 6 FT HT.
-------
-------------------------------------------=-------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
< Fee summary Charged Paid Credited
Due
Permit Fee Total 41.00 .00
00
41.00
Plan Check Total .00 .00
.00
.00
Other Fee Total 1.00 .00
.00
1.00
Grand Total 42.00 .00
.00
42.00
LQPERMIT
"Co ( b
P.O. BOX 1504
i'
LA QUINTA; CALIFORNIA 92247-1504
78-495 CALLS TAMPICO BUILDING & SAFETY DEPARTMENT
LA QUINTA, CALIFORNIA 92253 (760) 777-7012
FAX (760) 777-7011
PRppERT�, p;WNE
S PACKAGE
Disclosures & Forms for Owner -Bind -
1.7110 t ers Applying for Construction Permits
T..
Dear Property Owner. >!C R . ER.TyOWNER
application -Ibu a building
g Permit has been sub .
specified t miffed in your name listing Yourself as the builder of the
We are.pr.�ovidin
Providing you with an Omer -Builder Property
�Ponsibilo- Jes and possible risk AclORpw, ec I m nt and Inf
Owner -Builder. We y°u 'nay Incur by having°riz►ation Verification Form to make You aware si red and y�! not issue a budding it this, Permit issued Y are of your
g returned this form to us at our oeBr-nisiaddr m Your name as the
unless you, the You�have read, initialed. your understand'
Property owner, obtain the ess indicated. An a of each provision,
Prior approv! of the permitting authorityent of the owner cannot execute this notice
OR'S ACKp�}pWLEDG
afRECTI01Ys; Read and initial
each statemeENT nt below t MCATION OF
Signify you underst or TION
�l . I understand a You
f' this information.
building pert that error pmcUCe of unlicensed persons is to have the property an Owner -Builder, may erroneously implies that the Property P P rty owner obtain an
and tris or heremployees Y be held liable P �' owner is providing his or her own l "Owner -Builder'
and subject to serious financial risk for any in labor and material
injtiries. I am willfullywhile working On m 3wies sustained b Personally- I, as
on m acting as an O y Property MY homeowner's insurance may Y an unlicensed
Y Property- caner -Builder and Person
am aware of the limits of my insuran a overage for injuries to workers
2. I understand building
construction and are not Kirin Permits are not required to be signed b
g a licensed Contractor to y Property owners unless they are responsible for the
�3. l understand as Fume � responsibility.
thyself from all "Owner -Builder" I am the
potential financial risk b g responsible Party of record on thepermit.
o Y Kirin a licensed Contractor and havin the a iledI understand that I may 1„{(Z g permit filed in his or her name instead of my
4. I understand Contractors are required by law to be licensed
Permits and contracts.
and bonded in California and to list their license numbers on
5. I understand if ! employ
of my construction is at or otherwise engage an
under state and f east five hundred dollars Y persons, other than California licensed Contractors, and the total value
federal law_ {$500), including labor and materials, I may be considered an e
X6. (understand if I " ,employer,,
o'`'e1 ent am considered an
S withhold payroll taxes, "employee,
under state and federal law,
co�Perrsation for each "employee -"taxes, provide workers' compensation d I must register with the state and federal
risk- I also understand m isability insurance, and contribute to une
y failure to abide by these laws may subject me to serious finaa fi10 nanc_RLial I understand under
sOcrW s cannot .le all California Contractors'
-legally build them State License Law, an Owner -Builder who builds single-family residential
subcontractors and the number of s �� the intent to offer them for sale
unless under contract with a licensed tructure., does not exceed four within any Calendar ear, work is performed b
general building Contractor. Y or all of the work is y licensed
Performed
P98. 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. iujaries 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.csib.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:
At L I agree that, as the party legally and financially responsible for this proposed construction activity, t 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 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.li'cettse form notarizatian-, or
other verification acceptable to the agency is required to be presented when the permit.is issued to verify the property
owner's signature.
Signature of16110property 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 asmy 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: 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 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 permil is issued to verify the property owner's signature.
Property Owner's Signature: I Date:
Bin #
City of La Quinta
Building 8L 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: 53 a
Owner's Name: Kay-46A Rai
A. P. Number:
Address: -1� U v
Legal Description:
Contractor , til
City, ST, Zip: a. v . CA 9�L5 3
Telephone: ."
Address:
Project Description:
City, ST, Zip:
-
C11 a 0 2p1 -.
Telephone:::
:.,>;,a: :;.
(7 G
State Lie. # :
City Lie. 4:
I I
Arch., Engr., Designer:
344
Address:
r
City, ST, Zip: f
)N;F�'i'�4iii.:: :S':: :•.:
Telephone: %"•' ' '�%:fi
.�
';:.;{:>r
State Lie. #:f: '•>>`^:::>:.>. };
`
Construction Ty Oc ancy:
Project a 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
Regrd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance. ,
Title 24 Calfs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2•" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed.
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:
'`' 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