09-0798 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LAQUINTA,.CALIFORNIA 92253
Application Number:709- 00CLO 0798���
Property Address: 78580 SAGUARO DR
APN: 646-312-043-93 -000000-
Application description: WALL/FENCE
Property Zoning: MEDIUM DENSITY RES
Application valuation: 2000
Applicant: Architect or Engineer:
LICENSED CONTRACTOR'S DECLARATION
4
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BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
: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'sState License Law for the
following reason (Sec. 7031 .5, Business and Professions Code: Any city o�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 exempttherefrom and the basis for the alleged exemption. Any violation of Section 70.31 .5 by
any applicant for permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_ 1
1, 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 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 contractorls) licensed _
pursuant to the Contractors'" State License Law.).
( 1 I am exempt under Sec. , B.&P.C. for this reason .
Date: (if • U, owner LP e,r
u 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
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
CAROL HERRICK
78580 SAGUARO DRIVE D.
LA QUINTA, CA 92253
Contractor:
Owner
Date: 7/27/09
O
7V—,—
Fi {l y r
7 ----------------------------------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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. '
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
NLJ 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
3700 of the Labor Code, I shall forthwith GGGeee��� with those provisions.
Date: `��`kpplicant: �_ 1
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
DOLL'ARS'1$100,0001. 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 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 this county to enter upon the above-mentioned property for ��inspEction purpose
Date: �gnature (Applicant or Agent):
Application Number . . . . . 09-00000798
Permit . . . WALL/FENCE PERMIT
Additional desc . .
Permit Fee 45.00 Plan Check Fee
.00
Issue Date . . . . _Valuation
2000
Expiration Date 1/23/10
Qty Unit Charge Per
Extension
BASE FEE
15.00
15.00 2.0000 HND BLDG 501-2,000
30.00
-------------------------------------------------------------------=---------
Special Notes and Comments
80 L.F. 6' GARDEN WALL AT EAST SIDE OF
PROPERTY; CITY STANDARD. .2007• CODES
-------------------------- ------ 7 ---------------------------------
Other.Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
Due
-----------------------------------
• Permit Fee Total 45.00 .00 ..00
45.00
Plan Check Total .00 00 .00
.,00
Other Fee Total 1.00 .00 .00
1.00
Grand Total 46.00 .00 .00
46.00
L
LQPERTIIT
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City of La Qdinta
Building 8T SafetyDtvtsion
Permit # P.O. Box 1504, 78-495 Calle Tampico
la Qulnta, CA 92253 - (760).777-7012
Building: Permit Application and Tracking Sheet
Project Address: i 8' ` 5$o SC,c Owner's Name:,
-.._ _A_ P. Number: v�
- ---- --------- -- -Address:-
Legal Description: City, ST, Zip: kc, odwtraTG tom, �-ra .
— CN -Contractor:-Telephone• - (� �►
Total Permit
Address:
Project Description: ' �� eopp'
---
City, ST, Zip:
Telephone:
,> :..
IOtGG O fU !fr
State Lic. # :
City Lic. #; .
Arch., Engr., Designer::
Address:
-
City., $T, Zip:
Telephone:
State Lic. #:
v� � •orf ;� _
� ��� � •'
f n° ` %`.�... <�:..
Construction Type: Occupancy:
Project '
� � type (circle one): New . Add'n Alter- Repair Demo
Name of Contact Person: G rrt �G✓/ 5
Sq. Ft.-
#. Stories:
# Units:
Telephone # of Contact Person: 60 - 8(p�— Y, g0:. Estimated Value of Project:
APPLICANT: DO.NOT WRITE. BELOW THIS LINE
Submittal.
Plan Sets
Req'd
Rec'•d '
TRACMG
Plan Check submitted
PERMIT FEES
Item Amount
Structural Calcs.
Reviewed,. ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance •
Tithe 24 Caics.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2°" 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 .
I1V HOUSE:-
'rd Review,.ready for corrections/issue
Developer Impact Fee
Planning Approval
+,Called Contact?erson
A.LP.P.
Pub.. Wks. ApprDate
otpermit issue
School Fees
Total Permit
JUL-27-2009 MON 12;56 PM A&M CONSTRUCTION
FAX NO, 760 564 0406 P. 04
P.O. Dox 1504
LA QUINTA, CALIFORNIA 92247-1.504
79.-495 CALLC TAMPICO
LA QUINTA, CALIFORNIA 92253
BVILOING $ SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Y+ornis for Owiter-Builders Applying fur Construction Permits
.WBORTT!B-01IC—L TO PRQPLIRTY OWNEM
Dear Property Owner:
An. application--for--a building permit�ras been bmitted in your name listing yourself as the builder of the property
improvements specified at %� �jQj O � ,�CA
We are providing you with an Owner. -Builder Acknow dgment and Info ' ation Verification Form to make you award of your
responsibilities and possible risk you may incur by harring this permit -issued in your name as the
Qwner-Builder. We tvill not issue a building pertrrit until you have rear], initialed your understanding of oach 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.
VIRM,CIIUAS: Kead'and initial eUChstateinent bel.Div to sijq'6 you understand or Verify this information.
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C4 YL[ ti .', y k > u,:;q:i° :,.. :� "•,.,:j t. �, .i v:. r•j , - is i . .
1 I'understund a frequent` practice of unlicensed' persons rs to have !lie• properry-o`wncr obtain ari •;`,Owner -B ilder" •
building permit' lhaf err'oni oirsly ii plies that the property owner is pia"vidins'llis' or'he"r'ow i'lab`o� and aitatertal personatly. ><;: as. •
art .Owner -Builder, may beheld 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 awaie of the limitsof my insurance coverage for injuries to workers
on myproperty.
i 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 l may protect
Y.
_If from potential financial risk by hiring a licensed Contractor and having the permit filed in his or tier name instead of my
oNvn.
Verm4-1 understand Contractors are required by law to be licensed and bonded in California and to tist their license numbers on
its and contracts.
020-5. 1 understand if I employ or otherwise engage any persons; other than California licensed Contractors, and the total value
of Iny construction is at least five hundred dollars -($500), including Labor and materials, I may be considered an "employer"
under state and federal law.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
government, witUtold payroll taxes, provide woikers' 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.
7 I undcrct�iad tinder Cali orrua
a Contrctors' Stat, c
1 icnsc Law, an Owner-Builderivho bullets single-family, residential
tinctures caiuiof .legally `b`tiild diem `with 't ie "inteint'"t6 offer 'tlicrn'for s�ile; '-u'nlcss`�a`/J work :ts pCrfonned Uy;:ticettsed
subcontractors and the number of, structures does not exceed four' within any calendar�yea.r, or all of the work is performed
uAd�r cui7ti4ct witha'licct�szCl gciieiiil 6"'id
ing.Contractof,
JUL-27-2009 MON 12,57 PM A&M CONSTRUCTION
FAX N0, 760 564 0406 P. 05
PinkS- 1 understand as an Owner -Builder if I sell the property for which ttris permit is issued, I may be held liable for any
ncial or personal. injuries suctadnerl by=iriiy,snbserttient owner(q) Ih:tt•result from any latent construction defects in the
worlonanship or materials.
QArvi:e,
I understand 1 may obtain more information regard'uig rely obligations as an "employer" from the Lntenttal Revenue the United States Small Business Administration, the California Department of Benefit Payments, .and the, California
p Yt
Division of Industrial Accidents. I also understand I may contact the California Contractors' Stater License Board (CSLB) at 1-
800-321-CSLI3 (2752) or www_cslb.ca.gov fpr more infortttation about licensed contractors.
410. 1 am aware of and consent to an Owner -Guilder building permit applied for in my name, and understand that I am the
party legally and (inancial!4, responsible for proposed �eogs"ction activity at the following address:
S S 0>
J
I. I agroc that, as the party legally and financially responsible for this proposed eonsuvction activity, .l will abide by all
hticubj6 laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify dtc issuer of this form ira►reediatcly of any additions; dOctions, or changes to any of the ittformatiois 1
ave .provided on ties form. Licensed contractors are re• tvlated by laws designed to protect the public. 1'f you eoz tenet with
someone who docs not have: a licenso, the Contractors' State License Board may be unable io assist you with any financial loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors maybe in -civil court. It is also
important for you to:understand that if an unliccmed Contractor or employee of that individual or firm is injured while working
on your property: you may be held liable fmr damages. if you obtain a permit us 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 he issued, this form must be completed •rod signed by the property owner and returned to
the agency responsible for isstiaibg; the permit. Note: A copy of the - prop owner's driver's.litertse; forret hotarieat�vn, or
other verification acceptable to the agency is required to be preicnted it -hen the permit is issued to verify the property
vwner'a- Si�garldre. '
/Of
Signalurc of property owner �'r'�i'1� Date: 7 2—%
r
Note: Tlrc fpllvwing Authorization Norm is required to be completed by the property owner only when designating
an agent of the property owner to -apply for a con4ruction permit for the Owner-Ruilder.
AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNI R'S BFiIALF
Excluding the Notice to Property Owner, the execution of which 1 understand is my personal responsibility, I hereby authorize
the follotting person(s) to act asmy agent(s) to apply for, sign, and rile the documents necessary to obtain alt Owner -Builder
Permit for my proieel_
Scope of Construction Project (or Description of Work):__ a c—k (,UGC_
Project Location or Address_ 12 R - �r 0 Ct14 cl ro, PCejct
Name of /authorized Agent: r- Tel No
Address of Authorized Agent: " 6)o r'c)
i declare under penalty of perjurythat I am the property owner for the address listed above and'i personally filled out the above
information and certify its accttraey_ Note: A copy of the owner's driver's license, form notarization, or other verification
acceptable to the agency is required to lie presented when thel rrnit is issued to verify the pr perry u vner's signature..
0Property Owner's Signature:�/�v�� Date: �7
W.
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