10-1136 (BLCK)P.O.BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Applicant: Architect or Engineer:
4.4
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 he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
y Oplicant for a permit subjects the applicant to acivil penalty of not more than five hundred dollars ($500).:
I n[) 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 anowner of
property who builds or improves thereon, and who contracts for the projects with a contractors) licensed'
pursuant to the Contractors' State License Law.).
(_ 1 1 am exempt under Sec. , BAP.C. fo is r ason
Date:wner-
C STRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is construction lending agency for the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address: '
LQPERMIT
Owner:
RICHARD AZEEZ
54-740 AVENIDA RUBIO
LA QUINTA, CA 92253
----------------------
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: • 10/29/10
U OCT-
Contractor: - ` 28 �O�O
Owner . C'ry I
-----------------------------------------------
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�11should become su ' ct to the workers' compensate provisions of Section
3700 of the abCode, I shall h th comply with those prov' on
ate: o�_,,Xp4kant:
WARNING: FAILURE TO SECURE WORKER ' MPENSATION COVERAGE IS UNL WFUL, AN HALL -
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.
I . 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 relatingto building c ction, and hereby authoriz pr sentatives
oI the unty to enter upon the ab e•mentioned prope f - ction purposes.,
Date/'O'X7'/SQn a (Applicant or Agentl:
r
Application Number:
10-00001136,'
Property Address:
54740 AVENIDA RUBIO
APN:
774-272-012-13 -000000-
Application description:
.WALL/FENCE
Property Zoning:
COVE RESIDENTIAL
Application valuation:.2.342
Applicant: Architect or Engineer:
4.4
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 he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
y Oplicant for a permit subjects the applicant to acivil penalty of not more than five hundred dollars ($500).:
I n[) 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 anowner of
property who builds or improves thereon, and who contracts for the projects with a contractors) licensed'
pursuant to the Contractors' State License Law.).
(_ 1 1 am exempt under Sec. , BAP.C. fo is r ason
Date:wner-
C STRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is construction lending agency for the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address: '
LQPERMIT
Owner:
RICHARD AZEEZ
54-740 AVENIDA RUBIO
LA QUINTA, CA 92253
----------------------
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: • 10/29/10
U OCT-
Contractor: - ` 28 �O�O
Owner . C'ry I
-----------------------------------------------
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�11should become su ' ct to the workers' compensate provisions of Section
3700 of the abCode, I shall h th comply with those prov' on
ate: o�_,,Xp4kant:
WARNING: FAILURE TO SECURE WORKER ' MPENSATION COVERAGE IS UNL WFUL, AN HALL -
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.
I . 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 relatingto building c ction, and hereby authoriz pr sentatives
oI the unty to enter upon the ab e•mentioned prope f - ction purposes.,
Date/'O'X7'/SQn a (Applicant or Agentl:
r
Application Number . . . . . 10-00001136
--Permit . . . WALL/FENCE PERMIT
Additional desc .
Permit Fee .. . . . 54.00 Plan Check Fee .
.00
Issue Date' Valuation
2342
Expiration Date 4/27/11
Qty Unit Charge Per
Extension
BASE FEE
45.00
1:00 9.0000 THOU BLDG.2,001-25,000
9.00
----------------------------------------------------------------------------
Special Notes and Comments
85 L.F.6' GARDEN WALL & 10 L.F.'5'
GARDEN WALL, CITY STANDARD. 2007 CODES.
-----------------_-_-----------------------------------------
Other Fees . . . . BLDG STDS ADMIN (SB1473)
-
1.00
Fee summary .Charged Paid Credited
Due
Permit Fee Total 54.00 .00 .00
54.00.
Plan Check Total .00• .00 .00
.00
Other Fee Total 1.00 .00 .00
1.00
Grand Total 55.00 .00 .00
55.00
A
-P.O. BOX 1504
LA QUINTA; CALIFORNIA 92247•-1504
78-495 CALLE TAMP[co
LA QUINTA, CALIFORNIA 92253
BUILD14G & SAFETY DEPARTMENT
PROPERTY nVY EWS PACKAGE
(760) 777-70.12
FAX (760) 777-7011
Dfacfosures ,i Forms for Owner -$udders Applying for. Construction Pendts.
. -EY Ftnpaty Owner: _
.-A i. apiiicafiou .for a building Permit pas been submitted in.your name listingyourself as the hnilde€ of the :party
:we am pwiding you WM an Owner -Builder Acknowledgment and I n -da ifieation.Forat to make YOU
WSVOUS"Ii im and possible risk you may incur by ha ' this awatu _of your
4Brnes-•Builder. We w(� sot Issue a buil � Pe�t•is�Eci � y�oui:s � �e •
and returned ding permit until yWhave read:, initialed your understanding of each;provislon,
signed, this. form to us at our official address indicated An agent of the owner cannot execute llais:�tice
unless You, he property owner, obtain the prior approval of the permitting authority.
IV dead aird_ '7. r K: N
bribed each. statement eiTrwte—stgnyy you wmW3i ider'ver#yi*is irifo»nativn.
�. I understand a frequent practice of unlicensed ns is to: have the " ,
building permit that erroneously P a property owner obtain an Owner -Builder'
Y implies that the property owner is providing his.or her own lEbor and materia) p ift.1, as
Owner -Builder, may be held liable and subject to serious. financial risk for any injuries s-.istained by an unlicensed person
and his or ber employees while working on my property My homeowner's insurance maw not provide coverage .for those
m}cries. fam "'ilY acting as. an Owner -Builder and am a
.60 e4Y propatY- ware Of the. limits of my insuranc coverage for injuries to workers
�2. I understand building permits are not required to be signed b property owners ess the are responsible
construction and are -not hiring a licensed Contractor to .assume this Y P phi' tlrl y p role for the
responsibility.
&3 I understand as an "Owner -Builder" I.am:ihe res'ponsible;party of record on the pemAt. I understand that I may protect
y."„' from potential financial rislt b Kirin a licensed. Y g Contractor and having the permit filed in his or her name instead of my
ow//n''•��
/,!/4, I understand Contractors are required by law to be licensed and bonded in
penruts and contracts. California and to list their license numbers on
d5_ I understand if I employ or
otherwise engage any persons- other than California licen-ed Contractors, and the total value
of my construction is at least five hundred dollars ($500), incl
under state and federal law. uding labor and materials, I may be considered an "employer"
g&understand if T am considered an "employer" under state .and federal law, I must register with lite state.and federal
Mme-nt, withhold payroll taxes, provide workers' co
mpensation disability insurance, and contribilte to unemployment .
�mpensation for each "employee:" I also understand my failure to abide by these laws may subject me to serious ftnancial
risk
derstand under California Contractors' State License L. an Owner -Builder who builds single-family residential
cannot .legallbuild
Y them with the..
subcontractors and the number of sIntent to offer them for sale, unless ad work is performed by licensed
tructures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
�I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
ial or personal. ' '.ones sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
aoI understand I may obtain more information regarding my obligations as an "employer" from the l ifouenue
rvice. the United States Small Business Administration, the California Department of Benefit PaymeI*- and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLE4 at 1-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors..
I am aware of and consent to an Owner -Budder_ building permit applied for in my name, and understand that I am the
legally and f nancially resporishte ..fol proposed construction activity at the following address:
I agme that, as the party legally and financially responsible for this proposed contraction activity, .l will abide by all
app 'cable liws and re4airetY ehts that govern owner -guilders as well as employers.
e12.I
agree to notify the issuer of this form immediately of any additions, tiotrs,lirphVe s to tay of the� I
rovided on this form Licensed contractors are regulated by laws designed to protect the public. If You c Ontmet with
-someone who does not have a lic*erue,. @re Comtaetors' State License Board may be unable to. assist you with any 8naudd loss
You may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be inicivil court It is also
important for you toy understand that if w ualioonsed.Ceatractor or es€ tployee of that in&vidnad or frn eis in and white woddng
on your property; you may be hoU liable fm damages.' If you obtain a pernriE as Owner -Builder attd wish to hbM Conbuters,
you will be .resporisi o for verging v&tffiw or not those Contractors are pwpe€ y fieensed and the status of their walkers'
compensation insurance ooverp.
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 issubg, Ow Irermt. Note. A copy of the, prop. ergs an'aar's 4'ew'nt a+ f°m noft*0"4 or
other verification asceplable to the agency is,regrr&W to be promwed whernOvpamit is issue$ AQ vilify lire pMPeM
opener's signature. '
Signature of property owner Date:
Note: The following Authorization Fortis 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 (tuner -Builder.
Excluding the Notice to Property Owner, the exewtion of which I understand is my personal resp0nMb1hty, I hemVy authorize
the following person(s) to act as my agents) to apply for, sign, and file the documents necessarX to obtstin a4 0 CJ -Budder
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 coFy of the owner's driver's license, form notarization,.or, other verifreation
acceptable. to the agency is required to be preserited when the permit is issued to verify the property owner's signature..
Property Owner's Signature: Date:
Bin #
Permh #
10
Project Address:
A. P. Number:
Legal Description:
Contractor.
Address:,
City, ST, Zip:
Telephone:
State Lie. # :
Arch., Engr., Designer:
Ad4t+ess:
City., ST. Zip:
Telephone:
State Lk. #: .
Name of Contac Person:
Telephono # of Contaa person:
1/. Submittal Req+d
Pian Sets
Structural Coles.
"Muss Cala.
Title 24 Cafes.
Flood plain plan
Grading plan
Subcontactor List
Grant Deed,
H.O.A. Approval
IN HOUSE: -
Planning Approval
Pub. Wks. Appr
School Fees
City of La Quinta
Building a Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quanta, CA 92253 - (760) 777-7012
Building Permit Application and. Tracking Sheet
/.� Owner's Name -
Address:
City, ST, zip,,�T GL/A C7 9223
Tel
Project Dftcxiptioh:
%<
Lie. #;
Rec'd
Plan Check submitted
Reviewed, ready for co
Called Contact Person
Plans picked up
Plans resubmitted
2" Review, ready for
Called Contact Person
Plana picked up
Plans resubmitted
Review, ready for c
Called Contact Person
Date of permit issue
fancy:
'n Alter Repair Demo
# Units:
IRACK NG PERMIT FEES
item Amount
treedons Plan Chectc Deposit
Pian Cha* Balance .
Construction
Meehant�l
eorrectionsfusue Eleetrieal
Plumbing
SM.L
Grading
orrecdonwIssuc Developer Impact Fee
A.LP.P..
Total P:rmit Fees