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BWFE2047-005178-495 CALLE TAMPICO -e D NNNCl/ LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Application Number: Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: LUKE & AMY MILICK 50700 CALLE PALOMA LA QUINTA, CA 92253 BWFE2017-0051 50700 CALLE PALOMA 770095004 MILICK / 33 LF CITY STANDARD BLOCK WALL NEXT TO DRIVEWAY $5,000.00 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 Professions Code, and my License is in full force and effect. License Class: _ License No.: D1-te7 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 any applicant for a permit 4su_b'ects the applicant to a civil penalty of not more than five hundred dollars ($500).: . , 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 Ashe did not build or improve for the purpose of sale.). as owner of the property, am exclusively contracting with licensed contractors to '-Icbnstruct 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.). /^ am exempt under Sec. . B.&P.C. for this reason W Date: t EOwner:� 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: VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Owner: LUKE & AMY MILICK 50700 CALLE PALOMA LA QUINTA, CA 92253 Contractor: OWNER BUILDER Llc. No.: Date: 3/31/2017 WORKER'S COMPENSATION DECLARATION 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: _ _certify that in the performance of the work for which this permit is issued, Im shat not eploy 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,.l shall forthwith comply with those provisions. t� Date :3 Applies cant.—a411-4 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. APPLICANT ACKNOWLEDGEMENT IMPORTANT: Application is hereby made to the Building Official 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 this c' y to enter upon the above- mentioned property yffor riinspection purposes. / ' Date �I�/ ��' !/ Sienature (Aoolicant or Aeentl: t'i�-/ !E LU ti Qa I� N f.. = w 3 °- cra 0 , u_ uj - - U t` z WORKER'S COMPENSATION DECLARATION 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: _ _certify that in the performance of the work for which this permit is issued, Im shat not eploy 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,.l shall forthwith comply with those provisions. t� Date :3 Applies cant.—a411-4 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. APPLICANT ACKNOWLEDGEMENT IMPORTANT: Application is hereby made to the Building Official 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 this c' y to enter upon the above- mentioned property yffor riinspection purposes. / ' Date �I�/ ��' !/ Sienature (Aoolicant or Aeentl: t'i�-/ Application Number: Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: LUKE & AMY MILICK 50700 CALLE PALOMA LA QUINTA, CA 92253 BWFE2017-0051 Owner: 50700 CALLE PALOMA _ LUKE & AMY MILICK 770095004 50700 CALLE PALOMA MILICK / 33 LF CITY STANDARD BLOCK WALL NEXT TO DRIVEWAY LA QUINTA, CA 92253 $5,000.00 Contractor: OWNER BUILDER Llc. No.: Date: 3/31/2017 Detail: 33LF OF 5' GARDEN WITH GATE AT NORTH AND SOUTH SIDE OF DRIVEWAY[CITY SPECIFICATIONS] AND 3 PILASTERS[CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF CURB AND ANY FENCING SHALL BE LANDSCAPED, HAVE A SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016 CALIFORNIA BUILDING CODES. DESCRIPTION ACCOUNT:` ` '. QTY AMOUNT WALL/FENCE -'FIRST 100 LF 101-0000-42404 ( 0 $50.67 DESCRIPTION ACCOUNT QTY AMOUNT WALL/FENCE - FIRST 100 LF PC ^101-0000-42600 0 $63.33 .Total Paid for BLOCK WALL: $114.00 DESCRIPTION ACCOUNT.. I QTY AMOUNT BSAS SB1473 FEE 101=0000-20306'1 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT QTY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 J 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 Bin # Qty of La Q U*inta Buifdinc, &r Safety. Dhi.ision Permit 78-495 Calle Tampico La Quinta, CA 9M3 - (760) 777-701.2 Building Permit Application and Tracking Sheet - Project t A d Adm s s 0 — TA-W M A- +CC) CAU-45 A. P. Number: —Address;�-:+00 � A Legal Description: ic-ity-7STZip 7&A /U7-k.,04 11,_L255�3 ontract r:W_ I lC30bot Address: 7 City, ST, Zip: 4kT Telephone:ASt State Lic. City Lic.V.. Arch.,-Engr., Designer: - Address: City., ST, Zip: Telephone: LIU"IUIL lyp�t OccLipancy: State Lic. 9: Project type (circle one): New AdWn 'Alter Repair. 'Demo cN.-777 c--o. ---77771: a Y. Sq. Ft.: 1.# Stories: # Units: CT 17,-ph,.,-4-of-tontact.Person---S I: o IC—Estimated -Y-alue.of Project;' N Submittal Reqld APPLICAN T:: D 0 NOT WRITE BELOW THISIfLINE' Rcc'd TRACICENG PERMIT FEES Plan Sets Plan Check submitted Item - Amount Structural Calcs. -Reviewed,' ready for corrections Plan Clieck,Deppsit Truss Cates. Called Contact Person Plan Clicck Balance. Ti(!c24Ca1cs. Plans picked up .,Construction. Flood plain plan Plans resubmitted Mechanical Grading plan 2" Review, ready for corrections/issue Electrical Subcontac(or List Called Contact.Pcrson Plumbing Gran(Dccd Plans picked up S.M.I. lf.O�A. Approval Plans resubmitted Grading IN If OUSE:- Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person Pub. AVI.s. Appr Date of permit issue School Fees, Total al Permit Fees OWFE.201,7- CITY OF LA -QUINTA BOILDING & SAFETY DEPT, APV - FOR CONSTRUCTION - DATLO 3.'.)Pt7 By LF aft yo -:gLCiC4e vjAi-L 01-0 17 - 00 51 C 4 LoJA'.lA- — 'PALa,pA- So�-o 0 c� 4)L) r Kj 171- , Cdk— CIV.®F LA QUINT BUI.LDINCA..SAFETY .. D .cP.T. APp OVE FOR CQNSTRUCTION MT+E3 sZ � ol sY_.�-. PAyIE Z of Z { it P.'O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 BUILDING`& SAFETY DEPARTMENT - 78 -495 CALLE TAMPICo(760)777-7 .012 LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011 PROPERTY"„OWNER'. S.�7,'PACK-GE Disclosures & Forms for Owner -Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application • for a .building peftnit has been submitted, in our name listing yourself as the builder of the property improvements specified at�rj�-Q� pO—C i u•�#}'��(sOP�ITPti_; We are providing you with anOwner Builder Acknowledgment and Information, Verification Form to make you aware of your. responsibilities and possible risk you may incur by.having this permit.issued m yourmame as the Owner -Builder. We.will not.issue a 6uildmg:permrt-until you,have read, initialed your understanding of each provision, signed, and returned this form to us at ou"r 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. DIRECTIONS: Read and initial each statement belowto sig> un you derstand or verify' this information. K. I understand a frequent practice of unlicensed persons is to- have the property owner obtain an "Owner -Builder" dbug permit that erroneously implies •that the property owner. is providing his or her own. I ` or and-tiiaterial personally. I, as an Owner -Builder, may be held liable.aM-'subject to serious-fnancial.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. 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. 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 Contractorand having the permit $led in his or' her name instead of my own. . I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on perrruts and contracts. �. I understand if I employ or otherwise.engage any persons, other than California licensed Contractors, and the total value ofyconstru.ction is at least five hundred dollars ($5.00), .including labor and materials, I may be considered an "employer" under state and federal law. understand if I am considered an "employer" under state and federal law, I must register with the state and federal provide vernment, withhold payroll taxes, ide workers' ensati P mp on 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. I understand under Califomia 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. A8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any in—ancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue 4eligce, 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 (CSLB) at 1- 800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. lam. aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the egally, , and financially responsible for proposed�1 construction activity at the following address: �t� CA-i�c-r; Ar L_ ig V 1 MT -A- e k 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. 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. 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 -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 buildingpermit 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 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. �,,� 1 // -�, - Signature of property owner . ✓Date: 3 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, I 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 bepresented when the permit is issued to verify the property owners signature. Property Owner's Signature: Date: '✓ j gg.,�- -i s k.�fa,s�'vdd7�,»"'kSb++' -Tc ♦ R ' ME x° r e _ n _". ,try, ;�; .,� ,,,K'�i'-i "`" M� •. J iC�.3� 4f E3 -i LM ._ gyp .t. 7 -� 'ti 'i�T'`�h'T'Jl�BJ�y. 7 4 lq a