12-0672 (BLCK)uMP.O. BOX 1504 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: 6/15/12
Application Number:. 12-00000672 j Owner ,
�Properfy Address: 51040 AVENIDA VELASCO CASAREZ MARICELA CISNEROS
APN: 773-065-026- - - 51040 AVENIDA VELASCO
Application description: WALL/FENCE LA QUINTA,' CA 92253
Property Zoning: COVE RESIDENTIAL ----=----------------r --�-
Application valuation: 2500 ,rti�
Contractor: ;I ° r s a� �"� �
Applicant: Architect or Engineer: Owner i N �� 20011
CITY OF ILA QL'NI
_________________________________________________________________________________________________
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 .1 hereby affirm under penalty of perjury one of the following declarations:
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-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: - -
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_ _ I certify 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 rkers' 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 ode, I hall forthwit oom y iih those provisions.
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by /_ /� -
annyapplicant for a permit subjects the applicant to a civil penalty. of not more than five hundred dollars ($500).: Date: �+"�J plicant: �"L_
1 � 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
—1 the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The WARNING,. FAILURE TO SEC RE 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 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.). APPLICANT ACKNOWLEDGEMENT
() I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of 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 arid restrictions set forth on this application. ' I . - -
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 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 permit issued as a-result of this application,
1 _) I am exempt under Sec. B.&P.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
/ r performed under or following issuance of this permit.
Date: �U �1u +z"rZ Owner: 2. Any-permit issued as a result of this application becomesnulland 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
V4C`C1NSTRUCTIb/N'rrJENDING AGENCY_ permit to cancellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify that I have read this application and state that the above information is c ect I gree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.). - city and county ordinances and state laws relating to b ilding nstruction, and eb a horize representatives
of this county to enter upon the above-mentioned pro 16 spection purp
Lender's Name: �, L , y9•�
Date:�ature (Applicant or Agent)
Lender's Address:
LQPERMIT
Application Number 12-00000672
Permit WALL/FENCE PERMIT
Additional desc .
Permit Fee 54.00 Plan Check Fee
.00
Issue Date Valuation
2500
Expiration.Date 12/12/12
Qty Unit•,Charge Per
Extension
BASE -FEE
45.00
1.00 9.0000 THOU BLDG 2,001-25,000'-
9.00
-- - ------ - - - - - -
Special Notes and Comments
GARDEN WALL oRCO DETAIL . 6 ' • X 10 0. ,L . F . ,
2010 CODES.
-------------------------------------------------------------
Other.•Fees BLDG'STDS ADMIX (SB1473)
1.00
Fee summary Charged Paid, Credited,
----
Due
----------------- ------ ---
Permit"Fee Total 54.00 .00. .00
541.00
Plan Check Total .00 .00 .00
.00
Other Fee Total, 1.00 00 .00
1.00 -
Grand Total 55:00 00`.. .-00
55.00
LQPERMIT
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BUILDING
APPRO ED Pr. EXHIBIT
FOR CONSTRUCTION
CASE NO.
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APPROVED BY. PLANNING DEP A TMENT
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APPRO ED Pr. EXHIBIT
FOR CONSTRUCTION
CASE NO.
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P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY O"EW S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms, for Owner -Builders Applying for Construction Permits
AW-ORZANT1 DIU .. PROP> RTY pM_
Dear Phaperty Owner:
An. application .for a budding permit has been. soli'teed in your name listing yourself as the .builder, of the .property
-imprevements specified' at 570 fo 4Lr4ri1G(QAAre4D.
We are providing you with an Owner -Builder AclmoWledgment-and, Information Verification Form to make you awamof your
respensbilities and possible 6* you may incur by having ddspermit.issued. in your name as :the
Owner --Builder. We wOl not issue a buRding.pennit until you have read, initiated your %inderstanding of eacli`provision,
signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute "'Motice
unless you, the property owner, obtain the prior approval of the permitting authority.
Read initial each statementbetow-` b sign#y you uiidvstand`or v6.* this Wbrrrradon. .
understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Buddee,
building permit that erroneously implies that the property owner is providing his or her own labor and material penona#i.1, 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
mJ esI am willfully acting as an Owner -Builder and am aware of the limits of my insurance -coverage for injuries to workers
'on my Party.
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. .
I understand as. an "Owner -Builder' I am.tite res'
onsible,party of record on the permit. I understand that 1 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. 1.
4. I understand Contractors are required by law to be licensed'and bonded in California and to list their license numbers on
permits and contracts.
Vt-)--kI 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.
I .understand if I am considered an "employer" under state and federal taw, .1 muni, register with the state and federal
government, withhold payroll taxes,. provide woikers' 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.
L�XJL-r• l understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
structures cannot .legally build them with the .intent to offei 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.
W�l understand as an Owner -guilder if I sell the property for which this permit is issued, I may be bald liable for any
anctal or personal. 4uries tumked by any subsequent owners) that result from any latent construction defects in the
workmanship or materials.
U`�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 Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (Ckg) at 1-
800-321-CSLB (2752) or www.cs[b.ca.gov for more information about licensed contractors.
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 fitrmcially responsible for. proposed construction activity at the following address:
I agree that, as the party legally and ftnaecially responsible for this proposed construction activity, .t will abide by all
appli--27--,"agree
able laws and requirements that govern Owtier=ljuilders as well as employers.
O l2. I agree to notify the issuer of this form immediately of any additions, d+eletittns, or c 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 dOM not have a. license, the Coortraeiors' State License Board may be unable to asstba you with any 6nanetal loss
You may sustain as a result of'a complaint Your only remedy against unlicensed Contractors may be inleivil court. It is. also
important for you ter understand that -if an urdiocased.Contraetor or eroployee of that individual or fm is injured while woddng
on your property; you may be held, liable for damages. If you obtain a permit a Owner -Builder and wish to lure Cout><a€iors,
you will be r€spons,%le for verging vat of not those Com actors are prope€fy licensed and the status of their wottae &
compensation insumaoe 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 tssut%, t 1 a pw=Jf. Note: A copy of the preperty owner's dtiver .'v.ey f-0rW tm M or
Other venftteation acceptabte to the agency is requi -ad to be p when the pocmit is izueJ to vff* the prspert3'
owner's signature.
Signature of property owner Date: FvlL
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 OWNUR'S B1i';RaF
Excluding.the Notice to Property Owner, the eaewtion of which I understand is 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): fS C"q 0Pc; A -t, 0 A,L
Project Location or Address: 6( O `ib V \ �A V (, 'C5 �l0 `2 UL kAt A
Name of authorized Agent:
Address of Authorized Ager
F)3
I declare under penalty of perjurythat 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 ovine ' ver's license, form notarization, or other verification
to the agency is required'to be p .anted wh ape it is issued to verify the property owner's signature..
Property Owner's Signature. ate:
B,n.#
Oty.Of La Quanta
BuMdi v 8r Safety Division
P.O. Box 1504,78-495 Calle Tampico
La.QLdnta, CA 92253 - (760) 777-7012
Building PermitAp licatlon and Tracking Sheet
p g
Permit #
Project Address:Ajejoj r,
Owner's Name: .
cc la
A. P. Number.
Address: . t7 LI C101 C, ICA
Legal Description:
Contractor.
City, ST, Zip: N r CA
Telephone:
Address:
ProjeetDescription: CA •
City, ST, Zip:
Telephone:m=
State Lie. # :�City Lie. #;
Arch., Engr., Designer.
Address:
City., ST, Zip:
Telephone: Construction Type: Occupancy.
State Lic. #: ' Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:�. S.Ft.: #Stories: #Unit;;
Telephone # of Contact Person: 7&, r\83 f ` 63
Estimated Value of Project v u
- APPLICANT: DO NOT WRITE BELOW THIS UNE
#.
Submittal
RN'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount'
Structural Cntcs
Reviewed, ready for corrections
Plan Check Deposit. .
Truss Calce.
Called Contact Person
Plan Check Balance
Title 24 Coles.
Plans picked up
Contraction
Flood plain plan
Plans resubmitted • .
Mecharilcal
Grading plan
2'' Review, ready for correctionewue
Electrical
Subcoutactor List
Called Contact Person
Plumbing
Grant Deed
Pians picked up
ML
H.Or1. Approval
Plans resubmitted
Gradlug
IN IIOUSE:-
'^' Review; ready for eorrecdonsAssue
Developer Impact Fee
Planning Approval
Called Contact Person
A.U.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees