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10-0618 (ELEC)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 10-00000618 Property Address: 53620 AVENIDA RUBIO APN: 774-113-005-20 -000000- Application description: ELECTRICAL Property Zoning: COVE RESIDENTIAL Application valuation: 50 c&ttt 4 4 Q" BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Owner: ELIDIA P. MENDOZA 53-620 AVENIDA RUBIO LA QUINTA, CA 92253 -------------------- Contractor: Applicant: Architect or Engineer: Owner ------------------- VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 7/09/10 JUL 092010 D LA QUINTA ------------------------------7------------------------------------------------------------------ - LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations: 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 Labor Code, for the performance of the work for which this permit is 1�vt issued. te: — Contractor: fl— Com/- C✓ / r / .vy li r'9�� _ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor V Code, for the performance of the work for which this permit 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 the Contractor's State License Law for the Carrier Policy Number following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to V.1 certify that, in the performance of the work for 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, permit to file a signed statement that he or she is licensed pursuant to the provisions 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 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 any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: te: 7- 2-10 App' t:' FL[ CL—C,- —C,-1, 1,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 Law 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 ($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. 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.). (_) 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 am exempt under Sec. , B.&P.C. for this reason Date: 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 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 o enter. upon the above-mentioned property for inspection Purposes. � 0 S" ature (Applicant or Agent): alc__ i l Application Number . . . . . 10=0000.0618 Permit . . . ELEC-SERVICE CHANGE Additional desc . Permit Fee . . . . 33.50 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Expiration Date 1/05/11 Qty Unit Charge Per Extension• BASE FEE 15.00 1.00 18.5000 EA ELEC SVC <=600V/<=200A 18.50 Special Notes and Comments REPLACE MAIN BREAKER. 2007 CODES. ----------------------------------------------- Other Fees . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited Due Permit Fee Total 33.50 .00 .00' 33.50 Plan Check Total. .00 -.00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 34.50 .00 .00 34.50 P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 7$-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Bidders Applying for Construction Permits !l. TANTI NOT(PrR'ru QM � Dear Property Owner. Ari. application for a building permit has been submitted inyo narr}e listing yourself as the builder of the property impmve meats specified at 5-,3 (0 020 f-%1/e/� da,, KZt&J We are providing you with an Owner -Builder Acknowledgment and Infoimation Verification Form to make you aware o€ your responsibilities and possible risk you may incur by having this -permit issued in your name as the Owner -Builder. We Will not issue a building permit until ym,have read, initialed your understanding of a acliVraviden, 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. U 'S AQMO—W%E])G�� AND YE CATIEON OF U00 A IN DIRECTIONS: IONS: Read and initial each statement below to sign6 you understand or ver* this information. 1. 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. 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 injunies• I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my party. g -W-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 toassume this responsibility. "3. 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 Contractor and having the permit filed in his or her name instead of my own. rh ht4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ht5. 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. 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 taxes, provide woikers' 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. �7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residentia structures cannot .legally build them with the .intent to offer them for sale, unless all work is performed by licenser 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. f—ltq 8. 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 4.uries sustainedby any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. �even 9. I understand I may obtain more information regarding my obligations as an "employer" from the Interud Rue 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 (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. I am aware of and consent to an. Owner -Budder 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: 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable ('iws and requirements that govern Owner -Builders as well at; employers. �- 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or c> eg to any of the informz*tioa 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,. die 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 t& understand that if an unhocased. Contractor or employee of that individual or firm is injured while woddng on your property; You may be held liable for.damages. If you obtain. apermit as Owner -Builder. and wish to Dire Contractors, You will be .resPonatble-for verifying whether, or not those Contractors are properly licensed and the status of the'if workers' coon insuuame 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 Me permit. Note: A copy of the property' owner's diliver-.'s&wmf+ form nota 14 or other verification acceptable to the agency is required to be presented when the peemii is issued to verify the Property owner's signature. Signature of property owner ] C at Ct (p u, F-�r� G�'� Date: 07– Note: % 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 AGRNTTO ACT ON PROPERTY OWNEWS BEHALF Excluding the Notice to Property, Owner, the execgtion of which I understand is my personal responsibility, I hereby authorize the fallowing per&on(S) to act as my agent(s) 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: Bin # City of La Quint 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 # `V �b Project Address: Owner's Name: lk� enAza— A. P. Number: Address: ��5 c!,-Zo erg Legal Description: Contractor: City, ST, Zip: ;C�7_3 Telephon Address: Project Description: City, ST, Zip: Telephone: State Lic. # : City Lic. #- Arch., Engr., Designer: Address: City., ST, Zip: Telephone: State Lic. #: :::j���•.`;.s>>?%;<:vi<�:::��:•;>;>:,':.ConstructionT ;`£.<;M•;; >>,%<. e: Occupancy: Project type (circle one): New Add'n Alter epair Demo Name of Contact Person: -� Sq. Ft.: #Stories: #Units: Telephone # of Contact Person: Estimated Value of Project: . I APPLICANT: DO NOT WRITE BELOW THIS LINE 50 # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. i Called Contact Person Plan Check Balance Title 24 Calcs.' 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 resabmitted 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