09-1116 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
ADDlication. valuation:
Applicant:
09-00001116.
50825 CALLE RONDO
770-101-005-31 -000000-
RE-ROOF
LOW DENSITY RESIDENTIAL
4000
`:� 414'011;,«rw
Architect or Engineer:
0(
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
MORENO RICHARD ..
50825 CALLE G
LA QUINTA, 9 53 �•�
--- -
Contractor: ��N
Owner �Q.R�_Qli..
Date: 10/22/09
--------------------------------------------------------------------------------------------------
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter. 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: License No.:
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
Date: Contractor:
_ 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
OWNER -BUILDER DECLARATION
• insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier Policy Number
following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure,, prior to its issuance, also requires the applicant for the
iK person in any manner so as to become subject to the workers' compensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if I should become subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code) or
3700 of the Labor Code, I shall forthwith comply with those provisions.
' that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any ppIi 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
Dater licant: iTG�[ Y.7
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
WARNING: FAIL RE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
• improvements are not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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
ate:r: �re''b16`9
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
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, and hereby authorize representatives
of/th/is—county to enter upon the above-mentioned properVor inspection purposes.
ate
0 te. Si eture (Applicant or Agent):
LQPERMIT
Application Number . . . . . 09-00001116
Permit . . RE -ROOF
Additional desc .
Permit Fee . . . . 30.00 Plan Check Fee
.00
Issue Date . . Valuation
0
Expiration Date 4/20/10
Qty Unit Charge Per
Extension
BASE FEE
30.00
----------------------------------------------------------------------------
` Special Notes and Comments
RE -ROOF WITH 5.7 LB. EAGLE LITE ROOF
TILE. 2007 CODES
-------------------------------------------------- -
Other Fees .. . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
---------------------------------------------------------
Due
Permit Fee Total 30.00 .00 .00
30.00
Plan Check Total .00 .00 .00
.00
Other Fee Total 1.00 .00 .00
1.00
Grand Total 31.00 .00• .00
31.00
LQPERMIT
P.O. Box 1504
LA QUINTA,CA LIFORNIA'92247-1504
78-495 CAL -LE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
- -- -PROPERTY O'V"�NER'S PACKAGE
(7'60) 777-70-12
FAX (760) 777=7011
Disclosures 8r' Forms fof Owner -Builders Applying for Construction Permits
VKPORT NT! NOTICE To PROPERTY OWNER r
. Dear Property Owner.
An. application -€or -a- building permit has been submitted in your name listing yourself as the builder of the property
,-improvements specified at O — C
CA -
We are providing you with an Owner -Builder Acknowledgmeni and Information Veri ication 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 hive 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.
OVME-R'S ACKNNWLEDGIVIENT AND-VEREncATION OF INFORMATION
DIRECTIONS: Read and initial each. statement below to signify you understand or verify this information.
✓ l . I understand a frequent _practice of unlicensed persons is to, have the property .owner obtain an "Owner=Builder"
building periirit that eironeousjy" implies that the property owner is proiLidiiig his or h'er:owrr labor and material personally. 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.
✓ 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.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may-'protectmyself from potential financial risk by hiring a licensed Contractor and having the 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.
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_.l understand if I am considered an "employee" 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.
IT 1 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_
J8_ 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, injwies sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
`r 9. I understand 1 may obtain more information regarding my obligations as an "employer" from the Internal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand 1 may contact the California Contractors' State License Board (CSLB) at 1-
800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
J10.1 am aware of and consent to anOwner-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:
V I i. I agree that, as the party legally and financially responsible for this proposed constructio.0 activity, I 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 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: tYour only, remedy. -,against unlicensed Coptractors may be in civil court- It is also
important for you too 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 dtiver's.licensei form notanzattbn; or
other verification acceptable to the agency is required to be presented when the permit is issued to verify the property
owner's signature_
a
10440,111 ="111 , 01 M
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, l 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 Ommer's Signature: _ __ Date:
Bin #
City of La Quinta
Building 8r Safety Division
P.O. Box 1504, 78=495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit # 11
111
Oq
Project Address:tO 849WE ln=j LA
Owner's Nam .
A. P. Number:
Address: -.moo
Legal Description:
City, ST, Zip: LA qjjjVM,
Contractor:
ele h one:
TP
Address: O
Project Description:Bngr= 1
City, ST, Zip:
G1 �-. RWE ` --D
1�
UETelephone:
%«><��
State Lic. # :
City Lic. #:
Arch., Engr., Designer:
Address:
City., ST; Zip:
Telephone:
Construction n T
o e: Oyane
Type: Pu Y:
State to Lic. #•
Project type (circle n
cle one : New Add' n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: 41
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction: '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd 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:-
Jrd Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I,P,P,
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees