11-0084 (BLCK), � J
P.O. BOX 1504 4 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 1/24/11
Application Number: 11-00000084 Owner:
Property Address: 51100 CALLE OBISPO TORRES DANIEL
APN: 770-142-002-92 -000000- 51100 CALLE OBISBO
Application description: WALL/FENCE LA QUINTA, CA 92253 n a
Property Zoning: LOW DENSITY RESIDENTIAL (760)5.67-0133 U
Application valuation: 195 ;
JAN 2.,
Contractor: 2:11
Applicant: Architect or Engineer: Owner CITb'aF S A{J�UINTi�.,
,Ce% F �V%a' �E�'T .
L,%cif"
• LICENSED CONTRACTOR'S DECLARATION - WORKER'S COMPENSATION DECLARATION
I hereby affirm under .penalty of perjury that( am licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one oftFie following declarations:
Section 7000) of Division S 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:.' '
hereby affirm under penalty of perjury that I am exemptfrom 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 perforniince 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 person in; any manner so'as to become subject to the workers', compensation laws of California,
peimipto file a signed statement•that he or she is licensed pursuant to the provisioiis of the Contractor's State and agree that;rif I -should'; become. subject. to the workers; com 'gnsation provisionsbf Section
License L w (Ch ter.
with Section 7000) of Division'3'of the. Business'and'Professions.Code) or 3700 of the Labor Code,l.� 1'allforthwith.compl ith:th s ;prrsjon
_ that he r she is exempt therefrom and the.6asis-for the alleged exemption. Any. violation of Section 7031.5 by / '
any.a licant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (55001.: Date: ��E..' `Applicant: %
1 1, as owner of the property, or my employeeswith 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 WARNING: FAILURE. 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 CIVILFINES UP TO ONE HUNDRED THOUSAND -
and who does the work himself or herself through his or her own employees, provided thatlthe 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:(. APPLICANT ACKNOWLEDGEMENT
1 _ F I, as -owner of the property, am exclusively;contracting with licensed contractors to construct the,project.(Sec. IMPORTANT. Application.is1hereby.made to the Directorof Building and,Safety;for a,permit subject to the
7044,'Business and Professions Code:: -The Contractors' State.License Law does not apply to an owner of conditions and restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractor(s)Iicensed 1 . Each person upon whose behalf this application is made, each person at.whose request and for
pursuant to the Contractors' State.License Law.) - whose benefit work is performed under or pursuant to any permitissued-as�a result of this application,
1 _ I I am exempt under Sec. BAP.C. for this reason 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
\1
�7 performed under or following issuance of this permit.
Date: Z Owner: r /' 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
CONSTRUCTION LENDING AGENCY permit to cancellation.
1 hereby affirm under penalty of perjury that there is, a construction lending agency for the performance of the 1 certify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued ISec. 3097, Civ. C.). city and county ordinances and state laws relating to building construction, and hereby authorize re sentatives
�of this county to enter upon the above-mentioned property for insp tion purposes.
Lender's Name:
Date/Si gnature(Applicant or Agent):
Lender's Address: _
LQPERMIT
Application Number . . . . . 11-00000084
Permit . . . WALL/FENCE PERMIT
Additional desc .
Fee . . .,. 15:00 _
Plan Check-Fee
.`
.00 .
_Permit
Issue Date
Valuation
. . .
. 195
Expiration Date 7/23/11
Qty Unit Charge Per
Extension
BASE FEE
15.00.
Special Notes-.'and.Comments
t
8 ' LN. FT X- :5 FT HT •BLOCK WALL &'- (1)'
COLUMN 12-X 12 PER CITY STANDARDS •AND
APPROVE PLANS.
-------------------- .--- - - - - --
Other Fees BLDG=SIDS ADMIN (SB1473)
-
1.00.
Fee summary. 'Charged Paid
'Credited
Due
`
Permit-'Fee:Total 15.00,.
.00
.00
15.00
PYari=Check Total 00
.00-
.00
00
Other`" "Fee Total i.00•
00
00
1..00
Grand'-Total 16.00
.00
00.
16.00
LQPERMIT
.
Bin #•
_ ...
Ctyaof La. Qurnta
Bdiidlnjk Safety Division
P:O Box 1504, 78 495 Calle Tamplco
1.
La QU ta,.CA 92253-: (760) 777 -7012 -
A
,Building Perm>t App1[cat►on and Trkking<Sheet
Permit '#
I
1
Project Address:
Owner's Name
A. P. Number:
''`Address:
Legal Description:
City ST; Zip7-7777-7:
Contractor.
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Address:
Project Description:
City, ST,'Zio:
2
Telephone:n%::£<>:;>:;::,
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State Lic. # :
City.
ty:
•
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone:
Ps
State Lic: #:
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Construchon-Type: Occupancy:
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'4Pro'ect- a (circle one): 'New Add'n Alter Rep air Demo
Name of Contact Person:
',Sq:--Ft.:#.Stories:,
# Units:
Telephone # of Contact Person:
11 i
Estimated Value of Project: , ;
APPLICANT: DO'NOT WRITE BELOW XIIIS LINE',_
#
Submittal
Req'd
—Reed:
TRACKING . ` .
PERMIT FEES
Plan Sets
Plau,Check submitted
Item
Amount
Structural Calm
Reviewed, Iready 'for corrections
Plan Check Deposit
Truss Calcs.
Qlled,Contact Person
Plan Check Balance
Titre 24 Calcs.
Plans picked up
Construction '
Flood plain plan
Plans resubmitted.
Mechanical
Grading plan
1sd Review, ready for corrections/issue
Electrical
Subcontactor Iast
Called Contact.Person
Plumbing
Grant Deed
1 rPlans picked:up-,,
S.M.I.
H.O.A. Approval
Plans resubmitted'
Grading.
IN HOUSE:
''d Review; -ready for_corrections/'issue
-Developer Impact Fee
Planning Approval
Called Contact Person.
A.LP.P.
Pub. Wks. Appr
,Date of permifissue
School Fees
Total Permit Fees '
P.O. Box 1504
LA QUINTA' CALIFORNIA -92247-1504
78-495. CALLS TAMPICO
LA QUINTA, .CALIFORNIA 92253.
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER' PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
Ll
Of.�'O TWT! - NOTICE TO TROPERTY OWNER
Dear Property Owner.-.
'An. application for `building .permit has been' " 'mitted in° your name Lsting yourself. 'as the Builder of the,property
improvements specified at a^ p
We are providing you with an Owner=$uil 'r eknowledgmeri. and laoru ation Verification: Form to make you aware of your
responsibilities°and possible Tisk you may recur by having-th s:permit isW4e m your name as the
Owner -Builder. We will not issue a building permit until you have react; initialed your- understagding of each'provision,
signed; and returned this form to us at our oftieial address indicated. An agenf of the owner cannot execute this notice
unless. you, the property owner, obtain the'"prior. approval:of the permitting authority.
DfRECTIONS: Read anal rniticil eachstatement below to signify you bider stand'or'venfy.Ihis.information.
d_z7l. I understand a' frequent practice of unlicensed persons is toAave 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. I, as
an Owner -Builder, may be held liable andsubject to. serious. frnancial'xisk:for any injuries :,sustained by an unlicensed person
.and his or her employees while working on my props .- 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.
Y42: 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 Contractorto assume this. responsibility...
9JL3• 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. 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,thanCalifornia 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.
. 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 disabilityinsurance, 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.
)dZ7- I 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.
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. injuries sustainedby any subsequent owner(s) that result from any latent construction defects in the
worlananship or materials.
&79 I understand I 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 I may contact the California Contractors' State License Board (CSLB) at 1-
800-321-CSLB (2752) or www.cstb.ca.gov for more information about licensed contractors.
s0. 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:
11. 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.
�2. 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 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 dRiver,s,J!cemej form. notarization-, or
Other verification acceptable to the agency is required to be presented when the permit is issued to verify the praperty
owner's signature. n '
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):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
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 owner's signature..
Property Owner's Signature: Date:
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