11-0189 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Tityl °F 4Qg«rw
Applicant: Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
BELTRAN JOE I
54870 AVENIDA
LA QUINTA, CA
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/22/11
J UARE Z
92253
--------------------- —y��
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 declaratiosure ns: \\lir
Section 7000) 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-infor w s' 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:
I hereby affirm under penalty of perjury that I am exempt from 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 ertify that, in the performance 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,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State and agree that, if I should become subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or - 3700 of the Labor C+ I shall forthwith comply with thosvisions.
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
y applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: ate: AuaNt t:
I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and 0•� . _
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The WARNING: FAILURE TO SECU ORKERS' 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 CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the 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.).
(_ 1 1, 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.).
(_) I am exempt under Sec. , BAP.C. for this reason
Data.
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:
LQPERMIT
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.
I
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 county to enter upon the above-mentioned prope for inspection purposes.
bate: S' ature (Applicant or Agent)IF 11'
I—
. _7
Application Number:
11-00000189' /
Property Address:
54870-AVENIDA JUAREZ
APN:
774-266-007-18 -000000-
Application description:
RE -ROOF -
Property Zoning:
COVE RESIDENTIAL
Application valuation:
4000
Tityl °F 4Qg«rw
Applicant: Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
BELTRAN JOE I
54870 AVENIDA
LA QUINTA, CA
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/22/11
J UARE Z
92253
--------------------- —y��
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 declaratiosure ns: \\lir
Section 7000) 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-infor w s' 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:
I hereby affirm under penalty of perjury that I am exempt from 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 ertify that, in the performance 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,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State and agree that, if I should become subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or - 3700 of the Labor C+ I shall forthwith comply with thosvisions.
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
y applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: ate: AuaNt t:
I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and 0•� . _
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The WARNING: FAILURE TO SECU ORKERS' 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 CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the 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.).
(_ 1 1, 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.).
(_) I am exempt under Sec. , BAP.C. for this reason
Data.
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:
LQPERMIT
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.
I
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 county to enter upon the above-mentioned prope for inspection purposes.
bate: S' ature (Applicant or Agent)IF 11'
I—
Vim.
Application Number . . . . . 11-00.000189
Permit . . . RE -ROOF
Additional desc .
Permit Fee . . . . 30.00 Plan Check Fee
.00
Issue Date . . . Valuation . . .
. 0
Expiration Date 8/21/11
Qty Unit Charge Per
Extension
BASE FEE
30.00
-----------------------------7----------------------------------------------
Special Notes and Comments
RE -ROOF WITH OWENS-CORNING DESERT TAN
ASPHALT SHINGLES (35 YR.) INSULATION TO
BE ADDED TO CREATE R30 EXEMPT CONDITION.
2010 CODES.
w
---------------
Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
-------------------------------------
Due
--------------------
Permit Fee Total 30.00 .00 .00
30.00
Plan Check Total .00 .00 .00
.00
Other Fee Total 1.00 .00 .00
1.00
Grand Total 31.00 .00 .00
31.00
N
LQPERMIT
" i
ve Certificate of compliance: Residential Reroof
� 22t4eO-Z.
ROOFING PRODUCTS (COOL ROOFS) §151012
When the area of exterior roof surfaceto be replaced exceeds 50Y6 of the exlstf
roofing area must most the roofing product "Cool Roof" requirements of §15241
Check applicable alternative or exception below if the roof alteration is exempt from
CF -1 R-ALT-ReRoof
Climate Zone Permit #
1d 1 %/ —/C) `p�j
roof area, or 1,000 ffr, whichever is less, the new
H1, 152(b)1 Hii, or 152(b)1 Hili.
s roofing product "Cool Roof requirements::
❑ Cool roofs not required in Climates Zones 1-12,14, and 16 with a low sloped roof pitch (less or 2:12 pitch).
❑ Cool roofs riot required in Climates Zones 1-9, and 16 with a steep -sloped roofs (greater pitch than 2:12) and product weight less than 511b/ft?.
Alternatives to §152(b)1HI and §152(b)HII, Steep -slope roof (pitch > 2:12)
❑ Insulation with a thermal resistance of at least 085 hr•ft2•°FBtu or at least a 3/4 inch air -space is added to the roof deck over an attic; or
❑ Existing duds in the attic are insulated and sealed according to §151(f)1o; or
❑ In climate zones 10, 12 and 13, with 1 f12 of free ventilation area of attic ventilation for every 150 11:2 of attic floor area, and
where at least 30 percent of the free ventilation area is within 2 feet vertical distance of the roof ridge; or
® Building has at least R-30 ceiling insulation; or
❑ Building has radiant barrier in the attic meeting the requirements of §151(f)2; or
❑ Building has no duds in the attic; or
❑ In climate zones 10, 11, 13 and 14,. R-3 or greater roof deck insulation above vented attic.
Exception to §152(b)1Hill, Low -slope roof (pitch.S 2:12)
❑ Building has no duds in the attic.
Other Exceptions
❑ Roofing area is covered by building integrated; photovoltaic panels and solar thermal panels are exempt from the Cool Roof criteria.
❑ Roof constructions that have thermal mass 'over the roof membrane with at least 25 IbM are exempt from the Cool Roof criteria.
NOTE: If any one of the alternatives or exception is checked the Aged Solar Reflectance and Thermal Emittence requirements for roofing
products in §118(i) are not applicable. Do not fill table below.
Roof Slope I
CRRC Product ID Number' S 2:12 > 2:12 <
❑ F ❑
�Effs
Note: If no CRRC-1 label Is available, this compliance method cannot be used, use the Performance Approach to show compliance,
The CRRC Product /0 Number can be obta/r►ed fiwn the CoolRoof Rating Couna7's Rated Product Directory at www.000froofs.Qfl2a odu a1
Indicate the type of product is being used for the roof top, i. e. single -ply roof, asphalt roof, mental roof, etc.
If the Aged Reflectance quatiaV available intheCoo/ Roof Rati
directory and use the eqng Coups Rated Product Directory then use the Initial Reflectance value from the same
on (0.2+0.7p�„ — 0:2) fo obtain a calculated aged value. Where, p is the Initial Solar R@flectanoa.
Check box if the Aged Reflectance is a calmdated value using the equation above.
Calculate the SRI value by using the SRI- Worksheet at ftb:/Avww.enervv regwMe 2AI
acopy of the SRI- Worksheet to Are CF -1 R. and enter the resulting value in the SRI Column above and attach
roduct Weight
5lbfft2 i 5lb/fe
Product
Type2
Aged Solar
Refiedance3'4
Thermal
Emittance
SRIS
❑
❑
❑4
❑
❑
❑4
o apply Liquid Field Applied Coatings, the coating must be applied across the entire roof surface and meet the dry ml thickness or coverag
;commended by the coatings manufacturer and meet minimum performance requirements listed in §1180. Select the applicable coating:
I❑ Aluminum -Pigmented Asphalt Roof Coating ❑ Cement -Based Roof Coating
NO When a Cool Roof is required, the installing contractor shall complete and sub
Declaration Statement
❑ Other
the CF -6R -ENV -01 for final
• 1 certify under penalty of perjury, under the laws'of the State of California, the inforrnatiori provided on this form is accurate and complete.
• 1 certify that the.energy features and performance specifications identified on this Certificate of Compliance conform to the requirements of Title 24, Parts
1 and 6 of the California Code of R ulations.
Name:
k �
Si ature:
Company:
Date:
P. :ss:
License:
For assistance or questions regarding the Energy
Standards, contact the Energy Hotline at: 1-800-772-3300.
/ / t
P.O. BOX 1504
LA QUINTA; CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
LWORTANTI NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your mune listing yourself as the builder of the property
improvements specified at
We are providing you with an Owner -Builder Acktowledpmat and Information Verification Form to make you aware of your
respowibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We w0l not issue a builder permit until you have read, initialed your understanding of each pcuviAon,
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.
OAR'S ACIiNOWI EOGMI(' AND WEII<I WATION OF 94FORMA'1RON
DMEC "'ONS: Read and initial each statement below to signify 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"
C �q
building Permit that erroneously implies that the property owner is providing his or her own labor and material personalty. 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
1IIJuries- 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.
(A 2. I understand building permits are not required to be signed by property owners unless they are responsible for the
onstruction 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
yself from Potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
n0L4. I 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 than California licensed Contractors, and the total value
----
of my construction is -at -Least_five hundred -dollars 5500 inclu — i ` --
under state and federal law. ( )� mng labor and matenals, I may be conssdered'an "employes"
6. I understand if I am considered an "e
mp to
yen" under state and federal law, I moat register with the state and federa
941
government, withhold payroll taxes, provide workers, compensation disability insurance, and contribute to unemploymen
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financia
risk.
7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residenti;
'structures cannot legally build thein with the intent to offer them for sale, unless all work is performed by license
subcontractors and the number of structures does not exceed four within any calendar year, or .all of the work is perform
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, houries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
9 I understand I may obtain more information regarding my obligations as an "employee, from the Internal Revenue
- -- -- -Service, the United -States Small Business -Administration, the California Department of Benefit Paymenta.- and the California
Division of Industrial Accidents. I also understand 1 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.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
arty legally and financially responsible for proposed construction activity at the following address!
agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
Va licable laws and Owner -
Builders rogwrenuents that govern Owner Builders a4 well as employers.
e12. l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
averovided 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, �e Conteactors' State License Board may be unable to asses you with any financial loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil caul. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured whik 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 wdl be responsibk for vaitjing whether or not those Contractors are properly licensed and the status of chair 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 issuift dw permit. Note: A copy of the property owner's driver's Hosm wo fwm fin+ or
other verification aeeepsWe to tie sgwicy is required to be presented when tie permit is isms/ to verify die property
owner's signature.
Signature of property o Date:
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 1 understand is my personal responsibility, I hereby authorize
the following person(,) 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: Tel No
-Address"ofAuthofiud Ageiit:
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 be presented when the permit is issued to verify the property owner's signature.
Property Owner's Signature: Date:
Bin #
City Of Ia Quintd
Building & Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
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Project Address:
Owner's Name:
A. P. Number:
Address: SWK 20
Legal Description: 4
A----
City, ST, Zip: Qutne.•- �a—d-1
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L&A
p(
Contractor:Telephone:
Address:
Project Descripfion: opvi�
lo,
City, ST, Zip:
Telephone:....,„.:.
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State Lic. # :
Arch., Engr., Designer:
City Lic. C.
I`
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Address:
City, ST, Zip:
Telephone:
State Lic. #:
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Construction Type: cupancy: joy
ProJect type circle one) New Add'n Alter CRep Demo
/
Name of Contact Person:
Sq. Ft.:#
Stories:
#Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Titre 24 Caics.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Gradin plan Grading P
2" Review, ready for corrections issue
Electrical ,
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:
3” Review, ready for corrections issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
r
r. jl,Q
Z^f
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