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11-1279 (BLCK)P.O: BOX 1504 78=495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 4 BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Application Number:__11-0 0401279_ Property Address: ="54825 .AVENIDA RAMIREZ APN: 774=295-016-4 -000000- Application description: WALL/FENCE Property Zoning: COVE RESIDENTIAL Application valuation: 476 Applicant: Architect or Engineer: 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 an applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 1$5001.: 1 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 notintendedor 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, 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.). (_ 1• I am exempt under Sec. , B.&P.C, for this reason Date: �1/0 9�f ner: ONSTRUCTION ING 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: l LQPERMIT VOICE (760) 777-7012 FAX (760) 771-7011 INSPECTIONS (760) 777-7153 Date: 11/29/11 Owner: MICHAEL JENSEN 54825 AVENIDA RAMIREZ LA QUINTA,-CA 92253 --------------------------------- Contractor: ' Owner WORKER'S COMPENSATION DECLARATION NOV 20111 i't� d 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 700 of the Labor Code, I sh II 10 thwit ly with those provisions. Da icant: . WARNING: FAILURE TO, SECURE WORKERS' COMPE A 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 comply with all '.city and county ordinances and state laws relating to building construction, an ereby authorize representatives of this coun to a er upon the above-mentioned pro pe f �. pect; n purpos c D � !� �� Signature (A ant or Agent): - LQPERMIT Application.Number 11-00001279 Permit . . WALL/FENCE PERMIT . Additional desc . Permit Fee . . . . . 15.00 Plan Check Fee .00. Issue Date . . . . Valuation 476 Expiration Date 5/27/12 Qty Unit Charge Per Extension BASE FEE 15.00 Special Notes and Comments "22 L.F. PROPANR FNrT,nq TpE PJUTw1DTC FROM 5.' DOWN TO 31,.CITY STANDARD. 2010 CODES. -----------------_-----------------------.----------------------------------- Other Fees . . . . . . BLDG STDS,ADMIN.(SB1473) 1.00 Fee summary Charged Paid Credited Due Permit Fee Total. 15.00 .00 ,.00 15.00 Plan -Check Total .00 .00 .00 •.00 Other Fee Total 1.00 .00` .00 1.00 Grand Total 16.00 ..00. .00 16.00 P.O. Box 1504 LA QU[NTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT 78-495 CALLS TAMPICO (760) 777=7012 LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011 PROPERTY OVM' ER'S PACKAGE Disclosures & Forms for Owner-BaUders Applying for Construction Permits NO WE WgR 'PRIZTY n � Dear Property Owner . tupiplieation for a building permit has bees submitted, in your name fisting yourself as the builder of the .property imprOwemeats specified at 5'L� g p- 6V FA1t,1>^ 444JJ e�L We am Providing YOU with an Owner -Builder AtIma vledgmentand h&nnatien Verification Form to make you aw ma:o€ your reSPOnsibilities and possible risk you may incur by halving *&permit.issued. in your name as .the Own" -Budder • We wig not issue a buillding.permit until ye hauve read, initialed your under of each:ptrovisiou, signed, and returned this form to us at our ofrteial address indicated. An agent of the owner cannot execute dais -notice unless you, the property owner, obtain the prior approval of the permitting authority. QW=!S KDOME AND nM CA'k'LON OF II W"MON DAWOWM. Read and antrd staretirerrr b�¢fow t� signify you wrdw3taed or very tis irijornuation t1: I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" ing perinit that erroneously implies that the property owner is providing his or her ovn labor and material persw a f i.1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injurits sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance Qaay not provide coverage for those injuries. 1 am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers t3. ,property. I understand buil dung Permits are not required to be signed by Property ownon unless they are responsible for oho; ction and are not hiring a licensed Contractor to assume this responsibility. I understand as an "Owner -Builder" I am lite cesponsible.party of rword on the permit- I understand that I may protect from Potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. lofy"�V . I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers o: Is and contracts. .1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total vale construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employe T6. state and federal law. 1 understand if I am considered an -employee, under state and federal law, I must register with the state and fede government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemploymi compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious 6nm risk. &7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family resided s ctures cannot legally build them with the -intent to offer them for sale, unless all work is performed by Boer subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perfon under contract with a licensed general building Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any fintancial or personal. buries 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 lnternd Rt �renue Sotvice, the United States Small Business Administration, the California Department of Benefit Paymedts. and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSM at 1- 800-321-CSLB (2752) or www.cstb.ca.gov for more information about licensed contractors. t10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the p legally and financially respons ble for proposed construction activity at the following address: k Ark r /tF Lf� ?cit nl ri✓ C -A- q to'S3 rl L I agree that, as the party legally and fmawially responsible for this proposed construction activity, I will abide by all hcable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions; deletions, or cbat>ecs to Any of the information I provided on this form. Licensed contractors are regulated by taws designed to protect the public. If you contract with someone who does not have a tic em, the Contractors' State License Berard msy 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 eWd court. It m also itnportsat for you to understand dm if an unlica sed Cou tactor or ewployee of that individual or firm is i FJMd while w"Ung on your property, you may be hddliable fi-r damages. If your obtain a permit asne Owr-Builder and wish to him Contractors,you will wbe �o for vetirying whethw or not those Coatractors are papedy licensed and the statto of thttir weft& oompensation insurance oovemp. Before a building permit can be issued, this form must be completed and signed by the property owner sad returned to the agency responsible for issf,&a perinlL Nota: A copy of eke propeeV oww's Mver'sAkwtsci fWW not i°n; or other verification awAqtdrle to the agency is required to be presented when ulna pwnU is issimi to strifj' the PmPeM owner's signature. Signature of property owner p„ Note: The following Authorization Form is t�egttired 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. AUTIEWRIZATION OF AGLt'lulT TO ACT ON PROPERTY 0"ER'S BEHA� Excluding the Notice to Property Owner, the exegution of which I understand is my personal responsibility, I hcroby authorize the following pennn(s} to act as my ageat(s) to apply for, sign, and file the documents nece=XY to obtain an OwnerBuilder Permit for my project. , Scope of Construction Project (or Description of Work): W&V AZA1,L Sa sZ"U /WA I�r2o Pkir Tek 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 al information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization. or other verT,,tion 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 # -7777 City of ` La Quin to . BUM109 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 # ` T1 Project Address: Owner's Name: I G ki�Ft—NS X110 A. P. Number: Address: 5 q!?AS Al erlvi, r74 94Ml t2,=7 -- Legal Description: City, ST, Zip:1—AQU/ IATA' 6A 'j2S- 3 Contractor: % �`y"z " Telephone: % .fi-{•v " :v t^ca ME Address: Project Description: City, ST, Zip: ZNS1' L TlD/L/ O;r NEW WAW— Telephone:(� 2r26 ely�l� �t1 OPANE-rAAJI< State Lic. # : City Lie. #; a- /�1/zst-17� g��?'t !:! Arch., Engr., Designer: S f 3 Address: City, ST, Zip: Telephone::>^:?>n State Lic. #:r, x>gr vrr_2:✓, m;..,. nstruction CoType: OccupanCY: YP Project type (circle one): New Add'n Alter Repair Demo Sq. Ft.: # Stories: # Units: Name of Contact Person: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS UNE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Cales. Called Contact Person Plan Check Balance Title 24 Caics. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2" Review, ready for correctionsrrssue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans'resubmitted Grading IN HOUSE:- Review, ready for correctionslissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees