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10-1178 (ELEC)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 10'00"0"O Tl"7'8 Property Address: 78430 PALM GARDEN PL APN: 643-181-005- - Application description: ELECTRICAL Property Zoning: LOW DENSITY RESIDENTIAL ^,ppliootion ':aluotion. 30 Applicant: Architect or Engineer: ,//Y 316 6- , BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Owner: POLLOCK ALAN R P 0 BOX 491 LA QUINTA, CA 92253 (.760)564-1670 Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 11/04/10 ° D Npy- 04 2010 ------------------------------------------------------------------------------------------------- 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 7600) 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 OWNER-BUILDER'DECLARATI ON 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 or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by - n licant 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 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 soldwithin 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 _) 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 contractors) licensed pursuant to the Contractors' State License Law.).- ( 1 I am exempt under Sec. , B.&P.C. for this reason Date: A / Jill CONSTRUU DING 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 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 the workers' compensation provisions of Section /0�0 of the Labor C e, shall for wit triply wit those provisions. ' "Date:- (! -'Applicant:-- WARNIN : FAILURE TO SECURE WORKERS' C ERAGE IS UNLAWFUL, AND SHALL SUBJEC AN EMPLOYER TO CRIMINAL P � LTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS 1$100,000). IN ADDITION HE 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, and hereby a horize representatives of this co nt to enter upon the above-mentioned pro r y for Ri[ton rp ' W12 f—_- ,eu DateSignature (Applicant or Agent)' Application Number . . . 10-000011.78 Permit . . . . . . ELEC-MISCELLANEOUS Additional desc . Permit Fee . . . 15.75 Plan Check Fee 3.94 Issue Date . . . . Valuation . . . 0 Expiration.Date 5/03/11 Qty Unit Charge Per Extension . BASE FEE 15.00 1:00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20 .75 ---------------------------------- Special Notes and Comments GFI LANDSCAPE ELECTRIC PLUG FOR POND PUMP APPROVED PER G.B. --------------------------------------------- Other Fees . . . . ... . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited Due Permit Fee Total 15..75 .00 00 15.75 Plan Check Total 3.94 .00 .00 3.94" Other Fee Total 1.00 00 .00 1.00 Grand Total., 20.69 .00 .00 20.69 - LQPERn4IT P.O. BOX 1504 LA Q[JINTA; CALIFORNIA 92247-1504 78-495 CALLE TAMPIco LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S -PACKAGE (7'60) 777-70.12 FAX (760) 777-7011 Disclosures & Forms- for Owner -Builders. Applying for Construction Pernuits- VW PMUNT1 NOUCR.'r'Y OWNEIt Dear Property Owner. An . application for a building permit has. been sg6m tted inyour name.listing yourself as the buildef of theproperty property improvements specified at91 y� c �ry We are .providing you with an Owner -Budder Acknowledgment and. I ormation Verification Form to make you aware:of your responsibilities and possible risk you may. incur by having this permit-issuedis your name as the Owner -Builder. We will not issue a building permit untit ye.u:•have read, initialed your understanding of each`praAsion, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute thisMotice unless you, the property owner, obtain the prior approval of the permitting authority.. DIRECTIONS: Read im1 d initial eachstatement below to signify you understand`err verif tris information. R1. 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 providinghis or her own labor'and material persoriAy. 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. lam willfully acting as an Owner -Builder and am 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 114?f construction and are.not hiring a licensed Contractor to assume this responsibility- A/f%3 I understand as. an "Owner -Builder" I am the responsiblepparty of record on the permit. I understand that I may protect myself 6011i potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my • own. ,/y�4. 1 understand Contractors are required by law to be licensed.and bonded in California and to list their license numbers on jjj"""��� pernits and contracts. W5W5. I understand if I employ or otherwise engage any persons; other than California licensed Contractors, and the total value 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. I .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:" I also understand my failure to abide by these laws mayy subject me to serious financial risk 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential fractures 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. K-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 f ancial or personal. injur* sustained by any subsequent owners) that result from any latent construction defects in the wo anship or materials. ApI understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue rvice, 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 (CSf..B) at 1- 800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. 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 legally and financially responsible .for proposed construction activity at the following address: Wplic1 1. I agree that, as the party Legally and financially responsible for this proposed construction activity,.I will abide by all a ble 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 changes to any of the information I e 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 assistyou 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-Butder and wish to hire Conirantors, you will be responsible for verifying whether, or not those Contractors are properly licensed and the status of ftitf wotkers' 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 dieproperty owner's dkivwstiltcertae, farm rrota*advni or other verification acceptable too the agency is. required to be presented when the permit is issued to verify the property owner's signature. Signature of property owner Date: / ���• . / o[� 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 BFHAL 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 ) to. apply for, sign,and file the documents necessary to obtain ari Owner -Builder Permit for my project. Scope of Construction Project (or Descriptio of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjurythat I am the properk owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of th owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented ►v n the permit is issued to verify the property owner's signature.. Property Owner's Signature: Date: 0 Permit # Project Address: A- P. Number: Contractor Address�6��6: City. ST. zip: Telephone: Stage Lia # Arch., Bnpr.. Designer Adm: City. ST. Zip: Telephone: State Lia:. #: Name of Contact Person: # of Contact Person: # Submittal Plan Seh Structural Clea 'date 24 Calm Flood pWn pian Grading plan Subeonactor list Grant Deed H.O.A. Approval IN HOUSE: - Planning Approval Pub. Wks. Appr School Fees - - City of b Qwiifa . -- Building & Safety Division P.O. Box 1504, 78-495 Calle Tampko La Qulnta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet �ji4 er's Name 7W57 Z, /-17 Address: ! • v, e / Chy. ST. Zip:,e�ie 'Iietephorie:��0'S6�` 6 project Dasaiptiow City Lia #. x APPLICANT: DO NOT WRITE BELOW THIS LINE - - Rec'd Pian Check Re levoed. Called Cana Plans pldied Plans resuD 2'! Rewkw, Called Cana pic Pians ked Plans rest 3'4 Review, Called Con Date of 'R AC7CII�IG stbmitted ready mltted ready bmltted ready act pum PERMIT FEES Item Amot un for corrections n Type: Occupancy: ct Person (Code one): New Add'n Alger Repan Demo r Plan Check Balance.. up 9 Stories: i4 Units: alue of Project • 30 APPLICANT: DO NOT WRITE BELOW THIS LINE - - Rec'd Pian Check Re levoed. Called Cana Plans pldied Plans resuD 2'! Rewkw, Called Cana pic Pians ked Plans rest 3'4 Review, Called Con Date of 'R AC7CII�IG stbmitted ready mltted ready bmltted ready act pum PERMIT FEES Item Amot un for corrections Pian Csedc Deposit ct Person Plan Check Balance.. up Constructiondh Meankal for eorrectionsflssue Eloetrieal ct Person PlamtOng up S.M.1. Gig for eorrectlomquac Develbper Impact Fee Person A.LPP. It Issue Total Permit Fees