10-0434 (PAT)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T,iht 4 4 Q"
Application Number: 14-00000434
Property Address: 53580 AVENIDA RUBIO
APN: 774-113-004-21 -000000-
Application description: PATIO COVER - RESIDENTIAL
Property Zoning: COVE RESIDENTIAL
Application valuation: 1064
Ap�plic`ant: / Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
--------------------------------------------------
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 lAe or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
I ) Iscant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
._, 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 _ 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 amm exempt under Sec. , B.&P.C. for this reason
Date: 7 Owner'
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work foi which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
Owner:
HASSAN, RICHARD & JANET
1901 TOLL BRIDGE CT
ALEXANDRIA, VA 22308
(
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/14/14
------------------
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, 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
/3 J00 of the Labor Code, 1 shalMlfhh ortI ith hose provisions.
vDate: Applicant: f/�/l/L/
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 ($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.
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 Quima, 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 ty t/o/�/efnter upon the above-mentioned prope y o sspe'cIttion/n rpo s.
Date: �/ ' / Signature (Applicant or Agent):
Application Number . . . . . 14-00000434
Permit
PATIO COVER 2013
Additional desc .
Permit Fee . . .
. 95.81 Plan Check Fee
00
Issue Date . . .
. Valuation . . .
. 1064
Expiration Date
10/11/14
Qty Unit Charge Per
Extension
1.00 95.8100
EA MISC PATIO COVER, STD
95.81
----------------------------------------------------------------------------
Special Notes and
Comments
PATIO COVER 10 ' X
8' PER CITY STANDARDS
AND APPROVED PLANS
PER A.J. 2013CBC.
---------------------------------------------------------------
Other Fees . . .
. . . . . . BLDG STDS ADMIN (SB1473)
-------------
1.00
PLAN -CHECK, PATIO COVER
94.38
Fee summary
Charged Paid Credited
Due
-----------------
Permit Fee Total
---------- ---------- ---------- ----------
95.81 .00 .00
95.81
Plan Check Total
.00 .00 .00
.00
Other Fee Total
95.38 .00 .00
95.38
Grand Total
191.19 .00 .00
191.19
LQPERAI[T
lain #
Qty of La Quin to
-Building &r Safety Division
P.O. Box 1501,78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012•.
Building Permit Application and Tracking Sheet
Permit #
Project Address: d >J Ne✓
Owner's Name: t C.YIAY cf �, Cr_ yl
A. P. Number: 0
Address: 41F2V1, JJli-
Legal Description:
City, ST, Zip: o, Q u1,1 �Gt ZZ�3
Contractor:
Telephone:-
::::,>s> : s : ;; s<-: ;:» •>:z
Address:
Project Description:
City, ST, Zip:.
�yb p'd �"' o.
Telephone:
":s>>:>;:;;:.>.;:::. :.:.:..::::::..:,;.;;:.;:•.:.,,
i
State Lie. # :
City Lie. #:
Arch., Engr, Designer.
Address:
City, ST, Zip: .
Telephone:
P
W.Project
Constructi n Type: u an
fa #1
Ste Lic
a (circle ne • New Ado Alter Repair Demo
o
Name of Contact Person:
Sq. Ft.: 90
# Stories: I#Units:%
Telephone # of Contact Person:
Estimated Value of Project: SOO•, t'�
APPLICANT: DO NOT WRITE BELOW THIS LINE
/i Submittal Req'd Rec'd TRACKING PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cala.
Called Contact Person
Plan Check Balance •
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
god Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
I1.O.A. Approval
Plans resubmitted
Grading
IN I10USE:-
'"' Review, ready for correct ionsfissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
s
I �
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504 BUILDING &SAFETY DEPARTMENT
78-495 CALLE TAMPICO. (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
]PROPERTY"OWNEW S PACKAGE
Disclosures & Forms for OR%ner-Builders Applying for Construction Permits
me -Q4 NOTICE TO-MPERTY OWNER
Dear Property Owner
Am. application >.for a building permit: has been'': submitted in }roti name'' listing ` yourxeif gas ,the builder 'of the.'property
impe vawnts spocified at 53 0 fir► c�a >°'A 1,9 l'a Q u ter)
We are providing you with'an Owner -Builder Acknowledgmentand Infoimation`Vei fication'Foim to make you aware of your
responsibilities anddpossr-ble risk -you may incur by bxvuigthisponmit issued-in-your*nat`ne as"the '
Owner -Budder. 'We -will U0Uissue°a building :permit until you=have react; ididaled yotu 'tindersftidibg'of eacki provision,
signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute:this-noiice
unless you, the property owner, obtain the prior approval of the permitting authority.
alrF1'efertral Ad[le'SInlOrifnn/ /,olmi� Iii eim.i ". } � .. � .
�� %v •�nsi • iinra�fn�r� eii •iorily f%i.f iw�h7'7MifITAM
eugiunderstand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder''
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 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-
a2.
roperty2. 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" 1, am the responsible party of.record on the,pe L 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.
J&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.
A6• I understand if I am considered _ an "employee" 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.
AT I understand under California Contractors' StateLicense 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.
{
fay' 8. I -understand as an Owner -Builder. if I sell the property for which this pernut is issued, I may be he's: liable, for any
financial or personal. Wjaries 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 "employee' from the Iutreal 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 -IB) at 1-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
W10. 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 financiall ible , . for proposed construction activity at the following address:
53-8(9 A �1 �r o . �� Qom, Gg gzis`.3
11. I agree that, as .the party legally and Financially responsible for this proposed construction activity, .I will abide by all
applicable laws and requiretitents 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 inay.be unable to . 1 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 unlicensod Coutractoror 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 v6pow. or not those Contractors -are ,properly licensed and .the status of .their workers' .
compensation irr mane coverage.
Before a building permit can be issued, tiffs form must be completed and signed by the property owner and returned to
the agency responsible for isnua perm>it. Note: A copy of &e. progeny owner's driver's l et form nota vnr; :or
other veriTicadon acceptable to the agency is irquired to be'presen ed "en the. permit is issued to Verify the.prverly
owner's signature.
Signature of property owner �L�%2?� 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 ACTON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand. is my personal responsibility, I hereby authorize
-the followii persons) to act as' ` agent(s) to apply for, sign, and M- `the documents necessary fo obtain'an Owner -Builder
Permit foi 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:
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION.
DATE BY
bw ST►J
t
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
,.APPROVED
FOR CONSTRUCTION.
DATE BY
i