BWFE2016-0201Applicant:
OWNER BUILDER
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.:
Date: 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
is for thsubje alleged exemption. Any violation of Section 7031.5 by any applicant for a
rmit ects the applicant to a civil penalty of not more than five hundred dollars
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
e not intended or offered for sale: If, however, the building or improvement is sold
hin one year of completion, the owner -builder will have the burden of proving that
or she did not build or improve for the purpose of sale.).
S y I, as owner of the property, am exclusively contracting with licensed contractors
o construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
St License Law does not apply to an owner of property who builds or improves
eon, and who contracts for the projects with a o tractor(s) licensed pursuant to
ntractors' State License Law.). ,g
f � I am exempt under Sec. .'B.&P.0 oy'zf s reason
t Owner
t'
CONSTRUCTIO LE AGENCY
ereby affirm under penalty of perjury that there is a truction len g agency for
the performance of the work for which this permit is issued ( iv. C.).
Lender's Name:
Lender's Address:
VOICE (760) 7774125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:. 9/14/2016
Owner:
JASMINKO BESO •Fe
z
79085 OCOTILLO NSRg
78-495 CALLE TAMPICO
�aOWNER
LA QUINTA, CALIFORNIA 92253
DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number:
9WFE2016-0201
Contractor:
Property Address:
79085 OCOTILLO DR
" APN:
604264005
Application Description:
BESO / BLOCK WALL AT. FRONT YARD
Property Zoning:
Application Valuation:
$1,500.00
Applicant:
OWNER BUILDER
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.:
Date: 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
is for thsubje alleged exemption. Any violation of Section 7031.5 by any applicant for a
rmit ects the applicant to a civil penalty of not more than five hundred dollars
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
e not intended or offered for sale: If, however, the building or improvement is sold
hin one year of completion, the owner -builder will have the burden of proving that
or she did not build or improve for the purpose of sale.).
S y I, as owner of the property, am exclusively contracting with licensed contractors
o construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
St License Law does not apply to an owner of property who builds or improves
eon, and who contracts for the projects with a o tractor(s) licensed pursuant to
ntractors' State License Law.). ,g
f � I am exempt under Sec. .'B.&P.0 oy'zf s reason
t Owner
t'
CONSTRUCTIO LE AGENCY
ereby affirm under penalty of perjury that there is a truction len g agency for
the performance of the work for which this permit is issued ( iv. C.).
Lender's Name:
Lender's Address:
VOICE (760) 7774125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:. 9/14/2016
Owner:
JASMINKO BESO •Fe
z
79085 OCOTILLO NSRg
LA QUINTA, CA 92253ELL
�aOWNER
¢w�-
Contractor:
BUILDER
„-
z
Llc. No.:
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
*n”of the Labor Code, for the performance of the work for which this permit
workers'compensation insurance carrier an olicy number are:
Policy Number:
ertify that in the performance of fie wor for hich thisperm . issued, I
loy any person imany manner so 3s to b co subject to the or rs'
laws of California, and agree that, if o become �subject o e
pensation provisions of Section 3700 t r Co I all rthwith
conaplWwith those p ovisi ns.
Vh$RNING: FAILURE TO SECURE WORKERS' CO ATION COVERAG IS UNLAWFUL,
A D SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL ND CIVIL PINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION T 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 th;? 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 --ity 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 infor ti n is correct.
I agree to comply with all city and county ordinances and state laws r 7un
to building
construction, and hereby authorize representa•.ives of this city to ent r the
above-mentigned property for inspection purposes. /7.1. . IS
Signature (Applicant Dr Agent):
Date: ''9/14/2016
Application Number:
BWFE2016-0201
Owner: ,
Property Address:
79085 OCOTILLO DR
1ASMINKO BESO
_ APN:
604264005
79085 OCOTILLO DR
Application Description:
BESO / BLOCK WALL AT FRONT YARD
LA CjUINTA, CA 92253
Property Zoning:
r
Application Valuation:
$1,500.00
Applicant:
Contractor:
OWNER BUILDER
OWNER BUILDER
Llc. No.:
' Detail: 99LF OF 5'/6' GARDEN.WALL
AT FRONT [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK
SHALL BE COVERED WITH STUCCO; PAINT, OR TEXTURED
COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013 CALIFORNIA BUILDING CODES.
v
�.flNANCIALIINFORMATION
DESCRIPTION ACCOUNT. CITY AMOUNT
BSAS SB1473 FEE 101-0000-20306 0 $1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:. $1.00
DESCRIPTION ACCOUNT QTY AMOUNT .
WALL/FENCE - FIRST 100 LF 101-0000-42404 0 $47.86
.DESCRIPTION ACCOUNT QTY AMC)UNT
WALL/FENCE —FIRST 100 LF PC 101-0000-42600 0 $60.91
Total Paid for FENCE OR FREESTANDING WALL: $108.77'
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I'ermit #{
Project Address: o
7� � . 6)
City of La Quilito
Building 8i' Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
0 owner's Name: Q
UI/ . S�
A. P. Number:
Address: 7w�s CUAltfo D
Legal Description:
City, ST, Zip: " O_ act (n +0— n4 .0%
ract r• S
7Conth
TeleP hone•7GU 7—3
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Address: waeE W k) uv
Project Description: y(�
City- ST, Zip:oLaOit. I V I la
Ci -4- C1Z Z S
e hone•7 U
71Tel77 Z—
State Lic. # : ''"
Arch.,'Engr:, Designer:
Address:
City, ST, Zip:
.Telephone:
one:
truttion Type: u ecu sncY
�Cons
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State#
Lic.
dndtiter 2a
0ProJect type (circle one): New A'ai
Dem
Name of Contact Person: `
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: /,50019
APPLICANT: DO. NOT WRITE BELOW THIS LINE
tl
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cafes, _
Reviewed, ready for corrections
Plan Check Depc sit
Truss Calcs. .
Called Contact Person
Plan Check Bala:oce. .
Title 24 Calcs.
Plans picked up
Construction
Floodplain 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.
II.O.A. Approval
Plans resubmitted
Grading
IN IiOUSE.-
''d Rcyiew, ready for corrections/issue
�
Developer Impact Fee
i
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. APPr
Date or permit issue
School Fees,.
t
Total i'ermit Feas ,
T-Vf 4.4. 49h4
P.O. Box 1504
LA QUINTA; CALIFORNIA 92247-1504
78-49.5 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & ,SAFETY DEPARTMENT -
(760) 7774012
EPARTMENT
PROPERTY OWNER'S PACKAGE
(760)777=7012
FAX (760) 777-7011
Disclosures '& Forms for Owner -Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name isting yo if as the builder of the property
improvements specified at... 7-9 0<9 (!Q
We are providing you with an Owner -Builder Acknowledgment and Infibrination Verification 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 have 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:
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signs you understand or verify this information.
1. I understand a frequent practice of unlicensed persons is to have .the property owner obtain an "Owner -Builder"
wilding 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 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 pro-ide 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
XNny Property'
2. I understand building permits are not required to be signed- by property owners unless they are responsible for the
7 ction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect
If from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
V 4. I understand Contractors are required by law to be licensed and bonded in California and to list fieir license numbers on
ermits and contracts.
P 5. I' understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
f my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
qiidei state and federal law.
6: I.understand if I am considered an "employer" under state and federal law, I must register wi h the state and federal
g vemment, withhold .payroll taxes, provide workers' compensation disability insurance; and contruute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject :me to.serious financial
Yunde6contract
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
es cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
tractors and -the number of structures does not exceed four within any calendar year, or all of the work is performed
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 injirries 'sustained by any subsequent owner(s) that result from any latent construction defects in the •
%orkmanship or materials. '
I understand I may obtain more information regarding my, obligations as an "employer" from the Internal Revenue
S ice, the United States 'Small :Business Administration, the California Department of Benefit Payments, and the California
D,, ision of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
��0-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
r 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
legall fi0Z 1 ra11y s oCTO ble fo proposed nstruc o a i the following address:
I agree that, as the party legally and financially responsible for this proposed construction ac-ivity, I will abide by all
p licable 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 ta-any, of the information I
ave provided on this form Licensed contractors are regulated by laws designed to protect the pub=ic. If you contract with
someone who does not have a license, the Contractors' State License Board maybe unable -to assist yoi 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. Nate.'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. Q i
Signature of property owner Date: O-/ • 6) k C?D/ 6
"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 responsiblity, 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): '' CO (�(, v Q Ir l ' Lk)
Project Location or Address: _ 7 % 0 � S UCO / (7 �/ QU u CM q 2 Z rj
Name of Authorized Agent: Tel No,
Address of Authorized Agent:
I declare under penalty of perjury that I ani 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
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acceptable to the agency is required to b resented when the permit is issued to verify the property owners signature.
Property Owner's Signature:. Date:
NC/Gt/�,�vxv,-
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PROPERTY LINE 100.00' �; (E) 6' BLOCK WALL'
SITE PLAN
SCALE: 3/32" = 1'-0"
DATE �`t. +lV BY
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THE DEVELOPER / CONTRACTOR/ OWNER IS RESPONSIBLE
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FOR THE VERIFICATION OF EXISTING CURB LOCATION FROM
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PROPERTY LINES WITH PUBLIC WORKS DEPARTMENT
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PROPERTY LINE 100.00'(E) 6' BLOCK WALL
NEW 5'
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BLOCK,
WALL
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A.P.N.: 604-264-005
CURB
ADDRESS: 79-085 OCOTILLO DR- LA QUINTA,
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CA.92253
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LEGAL: LOT 67 MB 226/072 TR 23913
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SCOPE OF WORK:
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CITY OF LA QUINTA STANDARD
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REQUIREMENTS.
18"x18"x6'
NEW 5'
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PROPERTY LINE 100.00' �; (E) 6' BLOCK WALL'
SITE PLAN
SCALE: 3/32" = 1'-0"
DATE �`t. +lV BY
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