13-0507 (ELEC)wt (4k
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 13-00000507
Property Address: 53605 AVENIDA BERMUDAS
APN: 774-135-017-6 -000000-
Application description: ELECTRICAL ti
Property Zoning: COVE RESIDENTIAL
Application valuation: 475
Applicant:
T414t
0"*
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer:
------------------
LICENSED CONTRACTOR'S DECLARATION
1 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
'N&applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5001.:
,) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
Ir 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 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
Owner:
VANASSELT PETE
53605 AVENIDA BERMUDAS
PALM DESERT, CA 92211
(
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/24/13
D Q
APR 2 4 2013
CITY OF LA QUINTA
FINANCE DEPT.
WORKER'S COMPENSATION DECLARATION
1 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
9� 3 (000 of the Labor C� forthwith comp ith those provisions.
Date: 4) 1 �pplicant:
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.
'Ir
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 constructi ,and hereby auth rize representatives
of thi co ty to }�i��er upon the above-mentioned property for i ecti purposes.
Date:�•1..8ignature (Applicant or Agent):
(,:♦
Application Number
Permit . . .
Additional desc . .
Permit Fee . . . .
Issue Date . .
Expiration Date `.
. . . . 13-00000507
ELEC-SERVICE CHANGE
33.50
10/20/13
Plan Check Fee . . .00
Valuation . . . . 0
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 ELECTRICAL METER PANEL SAME FOR
SAME.2010 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
LQPERMIT
Brn.#
Qty of La Quinta
Building a Safety Division
Box 1504,78-495 Carie Tampico
La.Quinia, CA 92253 - •(760) 777-7012
Building Permit PP -A lication and Tracking Sheet
Pemtit #P.O.
Al
Proj Address:�� ��
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OzeesName:. e. C
A. P. Number.-2'cei
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Address:
Legal Description:
Contractor. koerg-
Address:
City, ST, Zip: �,�
Telephone: — (,
Project Description: e_A 6
City, ST, Zip:
V, ems-.
Telephone:
"4Cityir.
State Lic. # :
C,
Arch., Engr•, Designer.
Address:
City., ST, Zip:
Telephone:
State Lie. #:
Name of Contact Person:
[ Q
v
Construction Type:. 00 xupanry:
Project type (circle one): New Add'a Alter Repair Demo
Sq. Ft: q I # Stories: #+unit:
/ n
Telephone # of Contact Person:�ji Q = (� �7t1 Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS UNE
ii
Submittal
Pip Sets
Req'd
Recd
TRACIMG PERMITFF.ES
Plan Check submitted heat Amount
Structufal Carex
Reviewed, ready for corrections Plan Check Deposit, .
Truss Glu.
Called Contact Puaoa Plan Check Balance •
Title 24 CalcL
Plans picked up Construction
Flood plain plan
Plans resubmitted,' . Mechanical
Grading plan
2" Review, ready for corrections mut Meetr.cal
Subcoatactor List
Called Contact Person Plumbing
Grant Deed
Plans picked up S MLL
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE:-
''' Review, ready for corrections/issue Developer Impact Fee
Planning Approval
Called. Contact Person A.LP.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
i�M�111!Eril
4
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
P LOT! NOTICE TQ PROPERTY OWNER
Dear Property Owner.
An. application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at
We are providing you with an Owner -Builder Acknowledgmentand Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by halving this permit issued in your name as the
Owner -Builder. We will not issue a building permit until you leave read, inid" your understands of eaeb provision,
signed, and returned this form to us at our official address indicated. An agent of the owns cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
OZ'S Ae1MWLEDG'=NT AND'VERNWATION OF... 'i'ION
DIRECTIONS: Read and initial each statement below to signify you understand or verify dols infornration
tb. 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. 1, 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 ain aware of the limits of my insurance coverage for injuries to workers
on my property-
�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.
PL3. 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. 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 "employer''
under state and federal, law.
6. [ 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." 1 also understand my faihue to abide'by these laws may subject me to serious financial
risk-
. I undersiand under California Contractors' State License Law, an Owner -Builder who builds single-family residentia
F.
structures cannot legally build them with the intent to offer them for sale, unless all worts is performed by license(
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.
8: I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be he'd liable. tu.
financial or personal. bouries sustained by any subsequent owners) that result from any latent construction defects in thJ
workmanship or materials.
understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
ervice,
9. I 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 (CSLI) at 1-
800-321-CSLB (2752) or www.cstb.ca.gov for more information about tic, ensed contractors.
U10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
pay legally and financially responsible for proposed construction activity at the following address:
l 1. 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.
k12.1 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 ualwoused Contractor or employee of that individual or firm is injured while wottdng
on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contrwors,
You will be resimaMe for verifying or not those Contractors are pnopedy licensed and the status of their workers'
coon instunoe ooverage.
Before a building permit can be issued, tins form must be completed and signed by the property owner and returned to
the agency responsible for isstdag tie permit. Nota: A copy of tke property owner's Myer's 1kowei farar nrotar. MOM or
Other veritiCaden aeeeptabde so the agency is requkvd to be presented when tke permit is instead to verify the property
owner's signature.
Signature of property owner Date:
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 understandis 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): ,pA6L-r,.o� �CDCA-x`,kC 6�'►^ �O'✓If�Q/`
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 abovt
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 o be presented when the permit is issued to verify the prop rty owner's signature.
Property Owner's Signature: Date:
Investors Title Company
161 Fashion Lane, Suite 201
Tustin, CA 92780
(714) 586-8400 phone
(714) 665-4375 fax
GOVERNMENT CODE 27361.7
I CERTIFY UNDER PENALTY OF PERJURY THAT THE NOTARY SEAL ON
THE DOCUMENT TO WHICH THIS STATEMENT IS ATTACHED READS AS
FOLLOWS:
Name of the Notary:
Commission Number:
Date Commission Expires
County where Bond is filed:
Manufacturer/Vendor Number:
Place of Execution:
VERNON A. CURRY, JR.
N/A
11/11/15
ORANGE COUNTY
N/A
Tustin, CA
12/10/12
By: Lisa Anderson, Title Assistant
CommonlyyKnown As: 53605 Avenida Bermudas, la Quinta, CA 92253
Exhibit A
Legal Description
All that certain real property in the County of RIVERSIDE, State of California, described as follows:
LOTS 5 AND 6 IN BLOCK 240, UNIT 23 OF SANTA CARMELITA AT VALE LA QUINTA, IN THE
CITY OF LA QUINTA, COUNTY OF RIVERSIDE, STATE OF CALIFORNIA, AS SHOWN ON FILE
IN BOOK 20, PAGE 25 OF MAPS, RECORDS OF RIVERSIDE COUNTY, CALIFORNIA.
APN: 774-135-017-9