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10-1024 (DSF)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 10-00001024 Property Address: 54283 AVENIDA RUBIO APN: 774-234-016-4 -000000- Application description: REMODEL - RESIDENTIAL Property Zoning: COVE RESIDENTIAL Application valuation: - 1500 T-it�l 4 4 Q" Applicant: Architect or Engineer: b�e - . P /A ------------------ LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 70001 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 V-- 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.). (_) 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 ate: AS caner: 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: / C LQPERMIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 9/30/10 Owner: SMITH MARILYN n -� 54283 AVENIDA f LA QUINTA, CA 2P3 n ; r 12010 Contractor: Gtr' :•Its: j Owner ------------------ 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 MM 3700 of Labor C shall forthwith com ly with ovist DateiV�_pplicant: - - r —i . �– 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 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 comp with all city and county ordinances and state laws relating to buildi stru ti reby a e atives of this coun y)to enter upon the above-mentioned pr, y for ins oses. Rlate:�o [ ignature (Applicant or AgenU: Application Number . . . . . 10-00001024 ------ Structure Information DEMO/REPAIR ----- Other struct info . . . CODE EDITION 2007/2008 ---------------------------------------------------------------------------- Permit . . . BUILDING PERMIT Additional desc . Permit Fee . . . . 35.00 Plan Check Fee 22.75 Issue Date . . . . Valuation . . . . 1500 Expiration Date . . 3/29/11 Qty Unit Charge Per Extension BASE FEE 15.00 10.00 2.0000 HND BLDG 501-2,000 20.00 ---------------------------------------------------------------------------- Special Notes and Comments DEMO 216SF PATIO COVER + FIREPLACE AND REPAIR WALL AT REMOVED FIREPLACE. THIS PERMIT DOES NOT INCLUDE WINDOW CHANGE OUT OR REROOFING OF THE EXISTING DWELLING. CODE CASE #10-5200.•2007/2008 CALIFORNIA BUILDING CODES. September 30, 2010 5:16:22 PM AORTEGA ---------------------------------------------------------------------------- Other Fees. BLDG STDS ADMIN (SB1473) 1.00 ENERGY REVIEW FEE 2.28 Fee summary Charged Paid Credited --------------------------- Due -------------------- Permit'Fee Total 35.00 .00 ---------- .00 35.00 Plan Check Total 22.75 .00 .00 22.75 Other Fee Total 3.28 .00 .00 3.28 Grand Total 61.03 .00 .00 61.03 LQPERMIT P�L -2 8 3 A\je+n�8c� 6 L� QU,Ma , C IN 9 i CITY OF LA QUIN IA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION nATF /Z�'S; DFkCF C -06-c-'54 54•1bS AMA, uAr QJPMZD P.O. Box 1504 LA QUINTA, CALIFORNIA -92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits 1AW02TANT! NOTICE TO PROPERTYOWNER Dear Property Owner. An. application for a building permit has been s bmetted in your name.listing yourself as the builder of the .property improvements specified'at S4-ZE3 Ajon CA a y"al 92ZT We are .providing you with an Owner -Builder 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 Owner -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. OAR'S ACKN0WLE1)GIVIEN1 AND VERIF1fCATION OF ROORNAMN DIRECTTONS. Read and initial' -each statement -below to`signify you understan d'or ver. A this info rma ti o n. f�1. 1 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 personAy. 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. 9-2. 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 to _assume this responsibility.. 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. 4,4- 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 "employee' 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 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. 7. I 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. SI understand as an Owner -guilder 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 V /wforkmanship or materials. �j / 9. I understand I may obtain more information regarding my obligations as an "employee, from the internal Revenue Z/ +++'��e---rnce, 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: e i 1. 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. I agree to notify the issuer of this. form immediately of any additions; deletions, or.changes to any of the information 1 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 lieense,. 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 n'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 diiver's1i'censet form rrota*ad014 or other verification acceptable to the agency is. required to be presented ' when. the permit is issues to verify the Property owner's signature. Signature of p ro Pe�Y owner A-r-rA gate 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 fora 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 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): X 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`Co be presented when the permit is issued to verify the property owner's signature.. y. Property Owner's Signature: Date: Oct 01 10 11:55a The UPS Store Oct 01 2010 9:48HM ooint'iwesz 4053489615 P.1 /OUCUCOZIO.J [understand as an Owner -Sunder if }.Bell the property for wbicb this permit is'issued, I may be held Iis6lc for any a+.aa•er Baa �. v"wuu.. 01"mw &VAnamem oy •any suosoqueat ow*er(s) adt, result ttom any latent const„retroo Oeioets is me w'orlmlawhip or materials. �j &9. [ understatid I may obtain more infonuatioo regarding my obligations as an "eWlbyw, from the hocra d R�evtune / vice, the United Staten SmW Business Administration, the CWomis Oepadment of Benefit Paymeffis. and the Calsfwuia _ _.____ _ ...........aa.o. a omr uaaeaavusu a uw] cVuiat:c iuC WLLWritla l.0arraGe0i3 .?talc l.K•CY7fo Ovwau �w�a.u� n. a- 800-121-CS1B (2752) or www.cs%.ca.gov for atorc infortnation about lieenwA wntractors. S�10. I am avnm or and consent town Owner -Builder building permitapplied for is my came, and understand that t am the party flegally and f1tw= ally r2poassbte AD& Propoeed Fonsttttetion activity at the following address: If, L n t'CL(..A-- (.1- t); f+c.O :a J 7 Z. . J_. j�L[ L I. a ve that, as the party kgR.Hy and fgumially regmusible for this preposod cowttuction activity..[ will; abide by all applicable laws and t64imwenn that govern Owdec-Builders as -yell as employers, I agree to notify tha issA r of ft form imme"tely of any adtbtiom; Moi=, or.chweew Worry of the Wormadm I have provided on this form Licensed contractors are regulated by laws designed to proton the public. if YOU eosstract with -someone who does tact hove et hees8er OW factors' Suute Lisette Board may be enable UD•aand ym with any fjaa=W lots r.I...�Jr ruaiuut as a mala or a cvnrpsaML Year only retaeay agaeest uatieeoeed Contractors rmy se Wesly" Coca. R W-3130 haat for YM W. Malershmd lim-if ant oubmoaed.Caatn4tor or eaVloyee of tW W ivW v d oc SM is 000d whsle vMed:ing on Yourlroperty, Yap stay lits he liaft f( r'�ea. f you obtains permit as Owaw.5%ikkr and wish to bite C.oMeotora. Yen aunt be MgMM". for.vetf#eysag or not thane Cormactors ars p meetly liken ad and tree SUMS of, ON* w+arirers, comptumton is fawc coverage. Before a badlding permit can be issued, glia form must be completed and signed by the property vWaer and retIMEM&d to the ascot g rasepotaclble for ieay�.tilr permk IV*ft 14.capW of efirrvpwV env Wx 'sl�eeraat farrwr steeaaa8o 4 er odor w 4kadvA aocq fratW 1e the gpursy is e"ubv d to be premewd >riren. dtr gowit is isana m. wa * dw PmPcM signatureofpmpertyoworr Dam Note: The followingAutho' iza[ion Form is required to be completed by the property owner only whets designating an agent ofthe Dr1o/tP.Y1.v Nwwor In'armfu f~47 �nnofrr�Nin .....+...� F... •Le !lr .. ..A..:t.ao. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OVMXR'S•�V Excluding.the Notice to Property Owner, the exertion of which l w den and is Foy persomal respoagihil#y. I besetiy authotsae •the ffoliowiog person(s) to act as. my age0s) to apply for, sign, and fill the domnig its necesawY to obum an Owner-Bttittiet Scope of construction Project (or Description of Work): Project IMatiori of Address •f, Name of u0.nth0ri=d Agent -1 Address of Authorized Ager - I declare tender penalty of perjury that I am the property owner for the address listed above and I pMOnally filled cul the above informaaion and certify its acauacy. Male: tf espy of the owner's drivers license, form Aotarizatron, or other ve i cadon arcceprable.to the agency is required'ro be presented when dte permit is isssied to verify the propertp owner's.signaterre.. j. Property Owner's Signaturelid Date.• I I I Bin # City Of La Quinra Building 8t 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: 5L(--Z&3 Q 0. `' Owner's Name:IAC6041A A. P. Number: Address: fFc Legal Description: Contractor: City, ST, Zip: CK '7!g a i' Telephone: Address: Project` Description: baml fi*VW,E City, ST, Zip:ice „ Telephone:"`•.<"• State Lic. # : Arch., Engr., Designer. ` :: .< • gmkg £%y , s City Lic. M .(. Iw ciss Address: City., ST, Zip: Telephone:``` f~>a State Lic. #:Project Name of Contact Person: S h Construction Type: Occupancy: type (circle one): New Add'n Alter Repair Demo Sq. Ft.: # Stories: # Units: -Telephone # of Contact Person: -51 `!r Estimated Value of Project:*j ; APPLICANT: DO NOT WRITE BELOW THIS LINE N Submittal Req'd Rec'd TRACIUNG PERMIT FEES Plan Sets Plan Check submitted Z Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Bal aace Title 24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 21 Review, ready for corrections/issue Electrical �. Subcontactor List Called Contact Person Plumbing �- Grant Deed Plans picked up S.M.L H.O.A. Approval Plans resubmitted Grading IN HOUSE:- Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person .I.P.P. -► Pub. Wks. Appr Date of permit issue School Fees(�w Its Total Permit Fees glwkm . (Z*A'tnt; to tw*