14-0485 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4bt 4 4 Q"
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
an applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
_ 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 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 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. , B.&P.C. for this reason
CONSTRUCTION LENUNG 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
Owner:
GARZA HILARIO
52190 AVE CORTEZ
LA QUINTA, CA 92
(
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/22/14
CIYY OF LA gUIN'FA
i'14e.�s�•;t:
DEPT
WORKER'S
EP T.
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 Code, I shall forthwith comply with those provisions.
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 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 6uch 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
pt -this -county to enter upon the above-mentioned property for 'spection purposes.
signature a (Applicant�nt):
LQPERMIT
Application Number 14-00000485
Permit . . . WALL/FENCE PERMIT 2013
Additional desc .
Permit Fee 47.19 Plan Check Fee
.00
Issue Date . . . . Valuation . . .
. 1250
Expiration Date 10/19/14
Qty Unit Charge Per
Extension
1.00 47.1900 LS MISC WALL., FIRST 100 LF
47.19
----------------------------------------------------------------------------
Special Notes and Comments
60 LN FT X 6 FT HT•BLOCK WALL PER ORCO
STANDARDS &APPROVED PLANS. PRECISION
CONCRETE BLOCK SHALL BE COVERED WITH
STUCCO, PAINT, OR TEXTURED COATING WHERE
VISIBLE FROM OUTSIDE THE PROPERTY.
2013CBC.
------------------------------------------------------'----------------------
Other Fees . . . . . . . . BLDG STDS ADMIN '(SB1473)
PLAN CHECK, WALLS
60.06
Fee summary Charged Paid Credited
--------------------
Due
-------------------------------------
Permit Fee Total 47.19 .00 .00
47.19
Plan Check Total .00 .00 .00
.00
Other Fee Total .61.06 .00 .00
61.06
Grand Total 108.25 .00 .00
108.25.
r
j
i
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO.
LA QUINTA, CALIFORNIA 92253
e
BUILDING &'SAFETY DEPARTMENT
PROPERTY O"ER'S PACKAGE
(760) 777-7.012
FAX (760) 777-7011
Disclosures & Forms for Ovc%ner-Builders Applying for Coinsttuction Permits .
�'f1TlY7'/ I�iUT�CE TQ �R�?PEktTX O�'A1ER
Dear Property Owner
Ari . application =fora building permit has • boen-: subarittod in your name listing + yourself �as Ahe builder of" the �Propedy
improvements spocified at
We are providing you with an Owner -Budder Acknowledgment-aad Information• Verification•Fohn to make you awam of your
responsibilities and possii-ble risk -you may incur by hivizigihispermit issuedin°your naino as the
Owner. Builder. -We will not;issue,a building. mit until -you -hive read, iiiitiaied your understanding of each'provision,
signed, and returned this form to us at our official address indicated. An agent of the owaer cannot• exmiiteAhis.notice
unless you, the property owner, obtain the prior approval of the permitting authority.
Read irad init of e=wstatement betaw`ta signify you iir clerstaniI iir verify this infor?k&ion.
�1. I 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 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 .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 rity property.
9'". 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..
3. I:understand as an "Owner -Builder" I am the responsible party of.mcord on the,permiL 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.ius, ead of my
own.
121-4 A. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
1-5. 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 ($500), including labor and materials, I may. be considered an "employer"
under state and federal law.
lCf 6. 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 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.
OY-f 7. 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.
8. 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, ijaries wsiaiaed 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 In(ernai Rc enue
Service, the. United States Small Business Administration, the California Department of Benefit Payments, and ibe California
Division, of Industrial Accidents. I. also understand I may contact the California Contractors' State License Board (CSLM 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
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.
12. I agree to notify the issuer of this form immediately of any.additibns; deletions, or changes lo any of the:inforitiatioii, I
have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you; contract with
:someone who does,nothave.a licenses &e Contractors' State. Lwense,Boardnnay.be unable to 1 loss . .
you may sustain as a result of a complaint_ Your only remedy against unlicensed Contractors may be in,civd,-court:It is -also
important for,yowtaun:if a
derstand4hatn nrtli�scd Contractor or employee: of that -individual orfirm is injured whiWworidng
on your property,' You may beheld liabkfiq dama$es.:If you. obtain a:permit,,.as..Owner-Builder and wish whirc;Contraetors,
you: wilf.b.-o responsrible_for: verifying ;or not :tltose- Contractors - are ;properly licensed;and..the status of'..thtir wo&cn' .
compensation .inomame.: coverage.
Before it building permit can be issued, oris form must be completed and signed by the property owner and returned to
the agency responsible for issawg tke permit.11fo[c. A copy of tlrcpr# erry owner's Over "0eWsej form no" or
other verification acceptable to`, the agutcy rs rcgrured to bereserited when the.'.permit is rssueil to renfy the P+oPer
h'
owner's signature.
Siginat"e of property owner p Date: L/ - 20 /�
. — .
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.
AUTRORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BERA.LF
Excluding the Notice to Property Owner, the execution of which i under; 11stand.:is my personal responsibility, I hereby authorize
the followui 'peison(s) to act as"MY agents) to aliply for, sign, and file the documents necessary.fo'obtain'an`Owner-Builder
Permit fo 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: --AA -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 #
Qty of La Quin to
Building &r Safety Division
P.O. Box 1504, 78 495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
b
Project Address:
Owner's Name:
A. P. Number:
Address: Z.% Ave- D 4
Legal Description:
City, ST, Zip: Y2 2 53
Contractor:el
T e hone:
`.?�^:':<�:�>::;:.;:r:<:;;:
Address:
Project Description:
City, ST, Zip:
Telephone:
State Lic. # :
City Lie. #;
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:h
one:
Constructionn type: e: O ccu an cY:
Stfot
e Lic #:
ProJ'ect hP circle one)::N w Add'n Alter Repair 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 Cates.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cales.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
21" 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:-
Reyiew, 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