11-1183 (BLCK)P.O: BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
,,::Application Number:
APN:
Application description:
Property Zoning:
Application valuation: .
Applicant:
11-00001183
52414 AVENIDA VELASCO
773-265-008-8 -000000-
WALL/FENCE
COVE RESIDENTIAL
1061
Architect or Engi
c&t�v 4 4a Q"
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 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 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 1 am exempt under Sec. , B.&P.C. forlthil 9bas*
Date:- ll)lal� 'Owner:
v t
CONSTR N LEN G 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:
BRAD HOFFMAN
52414 AVENIDA VELASCO
LA QUINTA, CA 92253
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-1153
------------------
WORKER'S COMPENSATION DECLARATION
Date: 10/28/11
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 I 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 subjectff
w rIt rs' compensation provisions of Section
3700 of the Labor Cod I sha orthw' h ith those provisions.
Date: Applicant: .
WARNING: FAILURE TO SECURE WORKERS' COMPENSA ONVESUPTO
E IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL 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 is correct.. I agree to comply with all
city and county ordinances and state laws relating to building construction, and h y authorize representatives
of this county to enter upon the above-mentioned prop or ins ection
'Date: Signature (Applicant or Agent):
Application Number
. . . . . 11-00001183
Permit
WALL/FENCE
PERMIT
Additional desc .
Permit Fee
27.00
Plan Check
Fee
.00
•Issue Date .
.
Valuation
. . .
1061
Expiration Date'.
4/25/12
Qty Unit Charge Per
Extension
BASE
FEE
15.00
6.00 .2.0000 HND BLDG
501-2,000
12.00
------------
----------------------------------------------------------------
Special Notes and,Comments
.49' L.F: X 51. HIGH
CITY STANDARD
BLOCK
WALL. PER APPROVED
PLAN.
-- -----------------------------------------------------------
Other Fees .
. . . . . . BLDG
STDS ADMIN (SB1473)
1.00
Fee summary
-Charged
----
Paid Credited
Due
-----------------
Permit Fee Total
----------
27.00
.00
.00
27.00
• Plan Check Total
.00
00
.00
.00
Other Fee Total
1.00
.00
.00•
1.00
Grand Total
28.00
.00
00
28.00
LQPERMIT -
4
idL►+otrGt�kw
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OVM' ER'S PACKAGE
(7'60) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Sanders Applying for Construction Pelrinits
1AM0.�TANTI NOWE To PRQpERTy QVVWR
Dear Property Owner
your name
application for
a at c r building permit has been. submitted in Yo listing, Yourself as the builder of the .property
POVeMentS
We are providing you with an,Own&-Buddy Ac r " ' '
—`knovvte�meat�and i'nfocaaaton Verification Form to make you avm.of your
respansbilities and Possible risk you may incur by having d&&peamit.issued in your name as..the
O'"ex-Builder. We will not issue a building -Permit until yem%have read, initialed yourunderstanding of ea&pmision,
signed, and returned this form to us at our oflicial address indicated. An agent of the owner cannot execute thi$• Douce
unless you, the property owner, obtain the prior approval of the permitting authority.
AND MWICATION 4F DWOMUMN
IfimMOM Dead aftd. initial e=h statPmentbdow m signify you understand or ver. #y this i0formration.
,1JA1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
Udding permit that erroneously implies that the property owner is providing his or her own labor and material petsonaft-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
injuries- I am wrl MY acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on try property.
1 ? ► 2. I understand building permits are not required to be signed byproperty 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 record on the permit. I understand that I may protect
13R l€ from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
o�f I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
t�` construction ' "
Y is at least five hundred dollars ($500), including labor and materials, I may be considered an employer'
under state and federal law.
A
6. I understand if I am considered an "employee" under state and federal jaw, I must register with the state and federa
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 financss
risk
'c
,, 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residents:
S,d ctures cannot .legally build them 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 performs
under contract with a licensed general building Contractor.
t8. I understand as an Owner -Builder if I sell the property for which this permit is issued;.1 may be held liable for any
ancial or personal..4n ies sustained by any subsequent owner(s) that result from any latent• construction defects. in the
workmanship or materials..,
ve
I: understand I may obtain more information regarding my obligations as an "employee' from the Internal Kev+enue
, 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 (CSLB) at I- .
8001-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
p,�l0, 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:
l L I agree that, as the party legally and fumacially responsible for this proposed construction activity, I will abide by all
app
licable laws and requirements w
that' govern Ow* as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions; deletions, or cbsnges 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 does not have a lkmw, die Contractors' State License Board may be unable to assist you with any financial: loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in'iIivil court- It is also
important for you toe understand that•if an udwensed Contractor or employee of that individual or tem is Wured while working
on your Property,you you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors,
you wilt be responsible for verifying whedw or not those Coutractors are properly lieeased and the staters of their woflcers'
compensation insurance ooverage.
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 ivruitrg; ffie,permit. Now A copy. of tke property owner's dWver's <'apttsai f"w n° n, or
other veriTkWon acceptable to the agency is "' uhed to be presented when the pFszral is to verify the property
owner's signature. '
Signature of property owner ��'� L.- 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.
AUTRORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BAF
Excluding.the Notice to Property Owner, the exewtion of which I understand is my personal responsibility, I hereby authorize
the following persons} to act as my agents) to apply for, sign, and file the documents necessary to obtain ttn 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 perjurythat I am the property owner for the address listed above and I personally filled out the abo-
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 lie presented when the permit is issued to verify the property owner's signature..
Property Owner's Signature: Date:
Bin # ..... .: _
... Qty `of'.La. Quihta
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 #
Project Address: /
A
Owner's Name: "7 .
A. P. Number: 1
Address:'
Legal Description:
City, ST, Zip: ,� 7
Contractor:
Telepho e: 6Z ��
- :vH:JkL
)fir:}:'d. 4<:`s� :..H i:as;.�L•]]/L•ii.:
Address:
Project Description:
City, ST, Zip:
4a I
Telephone:
•� r^iv f<:.;::x;;:<:;`.
City Lic. #.:
State Lic. # :
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone:
P
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Occupancy:
Construction P Y:
State Lic. #:•i.><
Project type (circle one) New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories: d
# 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 Cales.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction '
Flood plain 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.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for correctionsfissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees