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12-0104 (PLBG)0 P.O. BOX 1504- 78-495 50478-495 CALL TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 12-00000104-1_7 Property Address: 52590 AVENIDA JUAREZ APN: 773-281-005-19 -000000- Application description: PLUMBING Property Zoning: COVE RESIDENTIAL Application valuation: 300 Applicant: Architect or Engineer: BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 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'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 subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: 1 _ 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 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 contractor(s) licensed pursuant to the Contractors' State License Law.). (_ 1 I am exempt under Sec. , B.&P.C. for this reason Date: caner: 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: --*ZZ,•,LQPERMIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 2/06/12 Owner: BIEGER LAWRENCE M 52590 AVENIDA JUARE jl, �i ` UNKNOWN - CA 99999l! � !, ----------------rIQ�------------- I 3 1U s��L� �-C 2012pv Contractor: Owner 01',,—Y OF a.Az-JiNTA 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 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 to the workers' compensation provisions of Section _ / 3700 of the Labor Cod/e2, I shall forth[ f conU ly with those provisions. )ate:/icant: WARNING: FA RE 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 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 ' correct. I agree to comply with all city and county ordinances and state laws relating to building construction d hereby authorize representatives oft s//c77oun�tcto enter upon the bove-mentioned property or ins ec 'o urp DeO� L� /i ture (Applicant or Agent): Application Number . . . . . 12-00000104 Permit . . . PLUMBING Additional desc . Permit Fee 18.00 Plan Check Fee 4.50 Issue Date . . . . valuation' 0 Expiration Date 8/04/12 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 3.0000 EA PLB GAS PIPE 1-4 OUTLETS 3.00 ---------------------------------------------------------------------------- Special Notes and Comments - INSTALL -25 L.F. 3"-4" SEWER PIPE, STUB -OUT, TO PREPARE FOR FUTURE SEWER ` CONNECTION. 2010 CODES. 7 ------------------------------------------------------------------------ Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited Due Permit Fee Total 18.00 .00 .00 18.00 Plan Check Total 4.50 .00 .00. 4.50 Other Fee Total 1.00 .00 :00 1.00 Grand Total 23.50 .00 .00 23.50 LQPERMIT - P.O. $Ox 1504: LA QUtNTA; CALIFORNIA 92247-1504 78-495 CALLS TAMPICO LA QUINTA, CALIFORNIA. 92253 y BUILDING & SAFETY DEPARTMENT (7:60) 7.77-7012 FAX (760) 777-7011 PROPERTY OVMER' S PACKAGE 'Disclosures.&I Porn's for Owner -Budden Applying for. Construction Permits' TO Ply(IPli '� UWf�IIs D Dear Property Owner .. Aji. application for a buildin PC= ur name' as#ie b eti ofein-imiwvv ements• specified at -We am pmo-viding you with an Owner -builder Actrnowledgnieat•and- Initrima n Verifrcativrr Form tfn matte � t .of your feSP611sibilities and possiib6 tisk you may incur by having this permit.i mored in your name as :the Owner -Budder. We Will not issue a building.pennit ani you have read, initialed your understanding of each'provistoa, signed, and returned ihis form to us at our oflieial address indicated. An agent of the ownicr cannot execute this notice unless you, the Property owner, obtain the pfior approval of the permitting authority. OAR 'sLSO 'r Al''IDATM- OF Il OW"UMN DAW 0OM Read and antrd ear stawnew kelow-rd StV"fy you aw)"ami or Y dtis k+ farms on. - 1. 1 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 providing his or her own labor and material pessonall ji. I, as an Owner -Builder, may be held liable and subject to serio • c financiat rick for an injuries Sustained by an u ho-eused person and his or her employees while working on my property My homeowner's insurance may not provide coverage for those injuries. 'am winfulky acting as an Owner -Builder and am aware of the limits of my insurance -coverage for injuries to workers-- on property. 2. understand building permits are not required to be signed by property owners unless they are responsible for the co ction and are not hiring a licensed Contractor to assume this responsibility. 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 luring a licensed Contractor and having the permit filed in his or her name instead of my 0 I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on is and contracts. . I understand if I employ or otherwise engage any. persons, other than California 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 "employee er state and federal law. 6. I understand if I am considered an "employee, under state and €ederal law, I must register with the Mate and Peden government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemploymei compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious &mci: g.7 I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residents structures cannot legally build them .with the intent to offer them for sale, unless all work is performed by licens subcontractors and the number of structures does not exceed four within any calendar year, or all of thework is perform under contract with a licensed general building Contractor. understand as an Owner -Builder if I sell the'property for 'which this permit is issued, I may be held liable for any 4nan8cial or personal. injuries suaaked.by any subsequent owners) that result from any latent construction defects in the wo anship or materials: 9. I understand I may .obtain more, information regarding my obligations as an "employec"f bin the 1 revenue Service, the United States Small Business Administration, the California Department of Benefit Payment&v and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (C SLU) at I - 800-32 1 -CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party 1 ally and • f+rnnc responsible fere pro c0M tionowing address: 1. I agree that, as the party legally and financially responsible for this proposed constriction activity, I will abide by all Vprovided and requirements that govern Owner-BunIders as well m employers. to notifythe issuer of this form immediately of any addition; dele.#ions, or chi to -my of the informMion I on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a licsgrrsse, Bre Contractors' State License Board may be unable to assist you with MY 6naneial loss YOU may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be itkivivil ©ourL It is also ilnVot for.YOU to tutdershtnd thst if an unfieensed Contractor or employce of that individual or firm is irted while working on your property, you may be field liable for dameam If you obtain a permit as Owner -Builder acrd vA* to him Contractors, you vtrfll be resp9mMo for verWyivZ v&e&w or not those Contractors are propel Iy licensed and the sM s of tlre'ir wvkers' compensation insurance coverag,& Before x building permit can be issued, this form must be completed and signed by the prop" owner and returned to the agency responsible for issue; &a.permtL Nose: A copy of &epropertp awnrr's d*eR,'vRaewq fwm nv0WU*r4 or other verification acceptable to the agency is uired to be presented when the p47mit is issuto ' the propery owner's signature. ` Signature of property owner Date c�? 74/,_' 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. AUT$ORMATfON OF AGENT TO ACT ON PROPERTY OWNSWS_BE A_L Excluding the Notice to Property Owner, the execution of which I understand is my persimal responsibility, I hereby authorize -the following persons) to act as my agents) to apply for, sign, and file the documents necessary to obWn ari 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 aboi 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 be presented when the permit is issued to verify the property owner's signa(ure. . Property Owner's Signature: Date: Bin # Crt�r of Ld QuInta Bufiding 8t Safety Mision P.O. Box 1504,78-495 Caffe Tampico [a.Qutnta, CA 92253 -:(760) 777-7012 Building Permit Application and Tracking Sheet Permit # ' I to Project Address: Owner's Name: . 10a 4 . A P. Number. Address: �QQ Legal Descxiption:City, Contractor. ST, Zip:Is Telephone: Address: Project Description'. City, ST, Zip: Telephone: State Lic. # : City Lic. # Arch4 Engr., Designer Address: . City., ST, Zip: Telephone: State Lic. #:Project Construction Type:. Occupancy: type (circle one): New Add'n Alter Repair Demo Sq. Ft.: # Stori#units: Name of Contact Person: Telephone # of Contact Person: Estimated Value of Project; APPLICANT: DO NOT WRITE BELOW THIS UNE N Submittal Rcq'd Recd TRACMG PERMIT FEES• Plan Sets Pian Check submitted Item Amount Structural Cales Reviewed, ready for corrections Plan Check Deposit. . Truss Cafes. Called Contact Person Plan Check Balance Title 24 Cake. Pians picked up Construction Flood plaitt plan Plans resubmitted Mechanical Grading plan 2'j Review, ready for correctionsfissue Electrical Subeontactor Last Called Contact Person Plumbing Grant Deed Pians picked up S.M.L ILO.A. Approval Plans resubmitted Grading Ili ROUSE:- ''d Review; ready for correcdo'ns/issue Developer Impact Fee Planning Approval Called Contact Person AXP.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees I _I rxle-10�1.