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BWFE2015-0129Property Zoning: Application Valuation: $3,500.00 Applicant: SERRANO, JUAN J 51585 AVENIDA RAMIREZ LA QUINTA, CA 92253 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that) am licensed under provisions of Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code, and my License is in full force and effect: License Class: License No.::CONV:140528101254086687 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 applicant,for a permit subjects the applicant to a civil penally of not more than five hundred dollars $500) ( }22I as owner of the property, or my employees with wages as their sole compensation, will do the work, and the:structure isnot 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 in or offered for sale. If, howeier; the building 'or improvement is sold within one year of completion, the owner-builder.will,have the burden of proving that e gr ,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 he -Contractors' State License Law.).. f Y I am exempt under Sec. . B.&P.C. for this reason Date:' Owner." :.�1�yU��Gw 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: Contractor: SERRANO, JUAN 1 51585 AVENIDA RAMIREZ LA QUINTA, CA 92253 (760)485-1134 Llc. No.::CONV:140528 LWJ 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: Car, ier Polity Number: x� rtify that in the,performance of the work for which this permit is issued, I shall not-eniploy any person in any manner so as to become subject to the workers' comPensatibn laws of California, and agree that, if, I should become subject to the workers' compensation•provisions of Section 3700 o the Labor Code, I shall forthwith comply with those provisions. Dat2 Applican WARNING: FAILURE TO SECURE WORK EROS' COM PENSA ON 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 Building Official 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 anis county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above- mentioned property for inspection purposes. Da Signature (Applicant or Age -�� VOICE (760) 777-7125 78-495 CALLE�TAMPICO D FAX (760) 777-7011 LA QUINTA; CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT _ INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 5/20/2015 Application Number: BWFE2015-0129 Owner: Property Address: 51585 AVENIDA RAMIREZ SERRANO, JUAN J APN: 773125017 51585 AVENIDA RAMIREZ Application Description: SERRANO/70LF OF BLOCK WALL SOUTH PROPERTY LINE LA QUINTA, CA 92253 8�� Property Zoning: Application Valuation: $3,500.00 Applicant: SERRANO, JUAN J 51585 AVENIDA RAMIREZ LA QUINTA, CA 92253 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that) am licensed under provisions of Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code, and my License is in full force and effect: License Class: License No.::CONV:140528101254086687 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 applicant,for a permit subjects the applicant to a civil penally of not more than five hundred dollars $500) ( }22I as owner of the property, or my employees with wages as their sole compensation, will do the work, and the:structure isnot 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 in or offered for sale. If, howeier; the building 'or improvement is sold within one year of completion, the owner-builder.will,have the burden of proving that e gr ,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 he -Contractors' State License Law.).. f Y I am exempt under Sec. . B.&P.C. for this reason Date:' Owner." :.�1�yU��Gw 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: Contractor: SERRANO, JUAN 1 51585 AVENIDA RAMIREZ LA QUINTA, CA 92253 (760)485-1134 Llc. No.::CONV:140528 LWJ 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: Car, ier Polity Number: x� rtify that in the,performance of the work for which this permit is issued, I shall not-eniploy any person in any manner so as to become subject to the workers' comPensatibn laws of California, and agree that, if, I should become subject to the workers' compensation•provisions of Section 3700 o the Labor Code, I shall forthwith comply with those provisions. Dat2 Applican WARNING: FAILURE TO SECURE WORK EROS' COM PENSA ON 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 Building Official 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 anis county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above- mentioned property for inspection purposes. Da Signature (Applicant or Age -�� !, u r.. r< f-z-.Sf 1µe^Y�wt3A:3-��•} X4 v .a .�.,, '0., r. .:,85y",� 3.. �`� � t'..-�L`�-',,ayl'i:',J '��:,iw`�'^& .,_��PROP, DESCRIPTION � a� M Mt ACCOUNT � QT�IAMOUNT � ��t - �aPAID PAID�DATE , ?J+2,,.a�. Yt._yfi4i. S:1 +rErt. 'ai:4 :i.+.t.. 4n•ii3:-,'.=...A<pS>:_ �. a• r.. Y BSAS 561473 FEE 101'%0000 20306 '. 0 $T.00 $0,.00 t ` ^bra £v3 .E;p ...cst'sr�..is'.-.F-"fs �•"lx•'z+.er.. r 1 1'�.¢5h_'RtiAi �`f r METHOD$y�,.7 (ySxiCHECK # ,..CLMTDBY �l �•C P[� 3. PAD,.y)BY�3 ;1i., .4�#�i. LY-.'a1F:C$�3!.�f .`5�+A a3 ,1'i„A„ "k^'SrrYs^r.1i.S�l.._ R4"f? ' �.4+1..i�F� ..RECEIPT# - '+2r. Total Paid f646LDIN"G STANDARDS ADMINISTRATION BSAr $1-.00 •$0.00 j . :-.�F.I'll, r� 7, �U ' QESCRIFTIONr-, ACCOU.NT�", QTY3PAID P�AID'UATE sr S� 1..i73h KyYir}C{awiJ"�.�2i.�i;_s`0�.,'.t.??-Ml fl?.4*{§:it'[41�5C�C�v.+•^uS.Re.:'�'S!b CCM•.. 4�. .v. "_+�.^.a... x.,..V'3��.+.`+W..it7,;. 3� Q1•H.wYFV4�3{::tSb2Si�.5°�5iB.rYvi:*4!alaiLWc WALL/FENCE `-FIRST 100 LF 10`1-0 42404 - 0 $47 86 ` $0:00 � B s' � MET = `� RECEIPT � � y�*�,xratu�r��sn�.11Moll �+ t k:.u�rn*.•.,i�^ � `• :.. 2.>�.:r�' . , MODE# f a l t�� "my .. "tea-�•"uw "'4:';� ,H'Y�"'E;` " �r s*.,..t•', `Lt'5'§ .- ' k` s:'>a ar,Fg:: 5=8s.ht, COUN�T��QTY� sW F` rr 4asr'�- t AMOUNTPOP a"`` `; Mr.�;�� ,a :. AIU` a ;'. r.,�r•, PAID ATH; r`�DESCRIPTION�,� u•M t"AC WALL/FENCE,. FIRST 1001 PC ;. 101 0000;42600' 0 $60 91 s $0:00 latz ° . Y . � �: . ,1 - yd:lrt°,w.?t a i� - -,A x.: 9- aC �Ew?: +f},c�y s . ' _ 0-1 " ; � l • *ii`.h'x NSk'�'Y`. e'r",:° �'� i RECEIP#` 7' '`r.3: L,,;;ti -. -wgg �+ . �i*�:rf,sf CLTDBY 1 MM:.tRABs�u�?sd b Total Paid for,FENCEOR FREESTANDING WALL $108 77k .. ; ' $0 00 o � �x � � ��4 �. ,a.. E Y e ,� � '• � _ � `, r ^� o .. : �. a �', , . he O mow, v`*t� tdyr� +' ,; •iG' s�iz OS Description: SERRANO/70LF OF BLOCK WALL SOUTH PROPERTY LINE Type: WALL/FENCE Subtype: Status: UNDER REVIEW Applied: 5/20/2015 SKH Approved: Parcel No: 773125017 Site Address: S1S85 AVENIDA RAMIREZ LA QUINTA,CA 92253 Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 55 Lot: 5 Issued: UNIT 5 Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $3,500.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: 70LF OF 6' GARDEN WALL AT PROPERTY LINE. [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013 CALIFORNIA BUILDING CODES. km Fu HEUER Printed: Wednesday, May 20, 2015 8:30:48 AM 1 of 2 s SYSTEMS PARENT PROJECTS REVIEW TYPE REVIEWER' SENT DAT RETURNED z `STATUS'` ,` REMARKS FNOTES# i E DUE DATE .DATE Printed: Wednesday, May 20, 2015 8:30:48 AM 2 of 2 C SYS 7EMS 717.: if �;PAID:UATE RECEIPT # "CHECK.METHOD PAID �• �-' DESCRIPTION _: ACCOUNT _CITY AMOUNT PAID r` BY BSAS 561473 FEE 101-0000-20306 0 $1.00 $0.00 Total Paid forBUILDING STANDARDS ADMINISTRATION $1.00 $0.00 BSA: WALL/FENCE - FIRST 101-0000-42404 0 $47.86 $0.00 100 LF WALL/FENCE -FIRST 101-0000-42600 0 $60.91 $0.00 100 LF PC Total Paid forFENCE OR FREESTANDING WALL $108.77 $0:00 . TOTALS:0• 00 PARENT PROJECTS REVIEW TYPE REVIEWER' SENT DAT RETURNED z `STATUS'` ,` REMARKS FNOTES# i E DUE DATE .DATE Printed: Wednesday, May 20, 2015 8:30:48 AM 2 of 2 C SYS 7EMS O • � 1 P.O. Box 1504 LA` QUINTA; CALIFORNIA .92247-1504 78-495 CA.LLE'TAMP'166 LA QUINTA, CALIFORNIA 92253' BUILDING & SAFETY DEPARTMENT (760) 777-7012 FAX (760) 777-7011 Considering Becoming ;an Owner -Builder? Important information you,needao know BEFORE= pulling your permit! The term "Owner. -Builder:" can mean three different things: "Owner as Worker'.", "Owner as Con'tr(rcior" or "OWne'ras Employer" Understand each has Benefits or Risk, and it is possible to combine them! Hiring a California Licensed. Contractor means you do.not personally perform any of the construction work, the permit is not taken out in your name, you are not personally responsible for the construction and you are not an Ownei:-Builder. Instead, you become a "Customer". and California law provides you the benefit of protection..from poor workmanship, failure to finish the job and financial risk due to worker injury. " Bene'fit/Riil : ' Highest Benefits"'ri&the Least amount of Risk Owner -as -Worker is a type of Owner -Builder where you personally perform the construction' work,. the permit is taken out in your name and you are personally iiresponsible for. the'construction nianagerireiit;.kno.wledge, workmanship, and completion of the job. You benefit by not paying others to perform this work for you`and your risk depends on your;own,ability to complete the job successfully. Benefit/Risk: Possible Benefit with Low. Financial Risk Owner -as -Contractor is a type of Q.wner-Builder where you,personally act as.your own General.Contractor, the permit is taken out in . your name and. you hire California licensed.sub-'contractors, to perform .portions of the construction. work. WARNING: The benefit of protection provided by law when you hue only.'Califoinia licensed sub -contractors can turn. to serious financial risk if you .hire unlicensed contractors to perform any of the work. Beinefit/Risk: Possible: Benefit and Sigirifrcant•Financial Risk Owner -as -Employer is a type of Owner -Builder where you pay any unlicensed; individual to perform any construction work valued at more than $500.00, the permit.:is taken,out:in your'name•and you 'are"personally responsible for their employment requirements, supervision,. performance, safety and welfare while on your property.WARNING: Cost savings benefit can turn to serious financial risk if you fail to deduct payroll tares or provide workers compensation insurance for each worker.. Benefit/Risk: Possible Benefit with. Significant Financial Risk (Health and Safety Code Section 19827) The California Legislature declares an "urgent and statewide public interest in assuring" that contractors comply with Contractors' License Law, Business and Professions Code and Workers' Compensation Insurance requirements to ensure property owners are informed about, and protected from the following when improving their property as Owner -Builders: Fraudulent representations - Liability for worker's injuries - Liability for material and labor costs unpaid by contractors • Licensing requirements - Employers tax liabilities . Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects and include workmanship and workers' compensation issues Homeowners suffer financial harm due to defective workmanship and injured employees. Following are alarming examples of what has occurred with Owner -Builder permits: Example 1: Homeowner received insurance money to rebuild burned=doWh home. • Owner/Builder permit pulled to rebuild structure.* • Unlicensed contractor built substandard structure — must be torn down and replaced. ■_ Estimated financial injury is $225,000. • Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of the year. Example 2: Brother-in-law had active license but filed an exemption from Workers Comp. • Owner -Builder hires brother-in-law to install a new roof. ■ Employee falls and sustains multiple spinal and.extremity fractures as, well as a head injury and . remains in a coma to this day. ■ The Owner. -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic system and suffers injury that results in permanent disability. ■ The Owner -Builder did not have a homeowner's insurance policy on the. house against which to submit a claim. ■ The Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Did you know — unlicensed persons frequently have the property owner obtain an "Owner -Builder" building permit which erroneously implies that the property owner is providing his or her own labor and material personally? Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your property by an unlicensed contractor and his/her employees? Did you know — if you are considered an "employer" under state and federal law, you must register with the state and federal government, withhold payroll taxes, provide workers compensation and disability insurance and contribute to unemployment compensation for each "employee"? Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk? OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR YOUR CONSTRUCTION PERMIT P.O.- BOX 1504 LA QUINTA, CAL-IFORNIA 92247-115 04 BUILDING & SAFETY DEPARTMENT 78-495'CALLE'TAMPICO (760) 777-7012 LA QUIN.TA, CALIFORNIA 912253 FAX (760) 777-7011 PROPERTY .0 ER. S.?A--CKAGE-..-.. Disclosures &Forms for Owner -Builders Apply . ing for --Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owrie'r'. An application for a building permit has been submitted in your na . meAisting yourself as the builder of the property improvements specified at We are providing you withan 0'' o Owner -Builder and Information Ve. rification, Form to -make you aware of your responsibilities'and OossiW risk you may incur b— issued your name as the yIlivmgt this .issuea Owner -Builder: We will not issue a- building' your u of each provision, P n ' cannot signed, and returned this' for' mi to us at our -officiaP,'4' ,address indicated: kn'a g - this notice iddi sindicaP agent of owner cannot execute unless you, the property owner,,obtain the prior.approval ofthe permitting iluth6fitV. DIRECTIONS: Read and initial each statement below 10igkifx.you understand or,V*erifY- this is, information: 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 -hisior her, own labor andrhateridl personally. 1, as an Owner -Builder, may be held liable :and subject to serious financial,ri's'k• for*.'any injuries sustained by an unlicensed, person and his or her employees*. while working on my property',-My'home.owner?s *insurance, may not provide coverage for those injuries. I am willfully* acting as an.Owner-Builder*and am aware,of the lin-its.of my insurance coverage for injuries to workers on my property. 2. 1 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. ,.A3. I understand asan."Owner-Builder"'l am:the.responsible party of record on. the,permit. I understand that I may protect myself from potential financial.risk-by hiring. licensed Contractor and having.th6 permit;filed.in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and . to -list their license numbers on permits and contracts. IS 5. 1 understand if I employ or otherwise engage any persons,. other than California lidensed 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. 1 understand if I am considered an."empl6yer" understate and federal law, I must -register with the state And federal government, withhold payroll taxes, provide workers' compensation disability insuraiice, andcontribute to unemployment compensation for,each "employee." 1 also understand my failure to abide . by'.these laws may subjectI me to serious financial risk.' 7. 1 understand under California Contractors' 8tateLicense Law, an Owner -Builder who builds single -fa . mily 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 Contriiet6r. I—S8. 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 injuries 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 epartment 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. S'.)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 legal] and financi lly resp nsible for propose construction . activii at the following address: -��. �S ✓• M G y 4 f tfE Act t 1, h CSG 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and'requirements that govern Owner -Builders as well as employers. �S 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 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 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. Signature of property owner Date: S gobs 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 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: • J Qin # City of La Quinta Buildirig8i SafetyDivision P. Box'1504''7:8 .O495,Calle•Tampko La Quinta, CA 92.253 --(760);777 7012. Building Permit Application and Tracking Sheet Permit # Project Address: 8 1 e r Owner's Name: CU !i ,enctot D A. P. Number: Address: i Legal Description: Ci , // City, STZip: G-Gi i L2 Z -z �3 . ontr C actor: Tele hone _P 0 3 %3 Address: ` Project Description: C& �r Y�,C Ye City, ST, Zip: za al"i'Lf'kca Telephone: jj State Lic: # : Arch., Engr., Designer: Address: City., ST, Zip: F. Telephone: :.: Construction Type: Occup Lic. #: 'PrJect tyState :N w dd'n Alter R air Demoa circle one Name of Contact Person: Sq. Ft.; # Stories: ' # Units: Telephone # of Contact Person: Estimated Value of Project:: S Q a -- APPLICANT: DO NOT -WRITE BELOWTHIS LIN # Submittal Req'd `. Rec'd , TRACKING - PERMIT FEES Plan SetsPlan Check submitted Item ,: Amount Structural -Cales. -Review,ed; ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Title 24 Calls. , Plans picked up Construction ' Flood plain plan 'Plans r'es"ubmitted Mechanical Grading plan 2od 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:- I d,'Aeyiew,'ready'for corrections/issue' Developer Impact Fee Planning Approval. Called'Contact Person A.i.P.P. Pub. Wks. Appr Date ofperm' It.issue School Fees . ' Total Permit Fees T