13-0538 (RR)P.O. BOX 1504_ b'
78-495 CALLS TAMPICO
LA QUINTA,.CALIFORNIA 92253,
Application Number:
'Property Address:
APN: .
Application description
Property Zoning:
Application valuation:
Applicant: ^I.
13-00000538
52420 AVENIDA VELASCO
773-265-009-9 -000000-
RE-ROOF
COVE RESIDENTIAL'
2400
Architect or Engineer:
,rF �
BUILDING & SAFETY • •'•�
TMENT
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.:
a
Date: Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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 It or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any plicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
r 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
I 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 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.).
I I am exempt under Sec. , B.&P)C�fort reas
{Date: Z6l3 Owner:
S C LENDING AGENCY
I hereby affirm under penalty of perjury that h e nstruction lending agency for the performance of the
work for which this permit is issued IS, 30 , Civ. C.).
Lender's Name:
03 t�j
Lender's Address: \�
LQPFRAI IT
Owner:
JON LOUTSENHIZER
52420 AVENIDA VELASCO
LA QUINTA, CA 92253
(760)272-0951
Contractor:
Owner
NJ
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/26/13
APR 2 6 2013
DEPT.
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
(_certify that, in the performance oft a wor r which this permit is issued, I shall not employ any
person in any manner so as to ome bject to the workers' compensation laws of California,
and agree that, if I should bec a su i to the workers' compensation provisions of Section
3700 of the Labor Code, I s I fo ith comply with those provisions.
Date: w Applica
WARNING:' FAILURE TO S URE WO E CO PENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO I AL ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADD N 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 into atio is correct. I agree to comply with all
city and county ordinances and state jaws relating to building cons ctio and hereby authorize representatives
of this county to enter upon the above-mentioned property for in cti urposes.
Date: 7� Signature (Applicant or Agent): `
r
J
LQPMNI IT
Application Number . . 13-000'00538
Permit RE -ROOF
Additional desc .
Permit Fee'.... 30.00
Plan Check Fee
.00
Issue -'Date
Valuation . . .
. 0
Expiration Date 10/23/13
Qty* Unit 'Charge Per
Extension
BASE FEE
30.00
Special Notes and Comments
REROOF:WITH FOAM. LESS THAN CODE
REQUIRES FOR OOL ROOF, GB APPROVED
EXEMPTION FROM CF1-R. 2010 CALIFORNIA
ENERGY CODE.
--------------- --
Other Fees . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
'Fee summary. Charged Paid
Credited
Due
Permit Fee. Total 3.0.00
.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
LQPMNI IT
Bin. #
City of La Qu" to
Bulkling 8r Safety Dmsion
Permit #
P.O. Box 1504,'78-495 Calle Tampico
La.Quinta, CA 92253 - (760) 777-7012
� c)-
Building Permit Application and Tracking Sheet
Project Address:..
Owner's Name:. Q
A- P. Number.
��5j
Addr=: --67-M `v( e%, C O
Legal Description:
City, ST, Zip.
Contractor. _
Telephone: % Z O C7 5 /
Address:
Project Description:
City, ST, Zip:
Telephone:
State Lic. # :
City Lia 0,
Arch., Engr., Designer.
M ,
Address:
5
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
State Lic, i3:
Project we (circle one): New Add'a Alter Repair Demo
Name of Contact Person:
Stones:. A Unit
Telephone it of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THis UNE
M
Submittal
Roq'd
Recd
TRACKING PERMITFEES
Plan Sets
Pian Chock submitted Ierm Anoint
Strgctaiat Cates
Reviewed, ready for correcdow Plan Check Deposit.
Truss Cates.
Called Contact Person Pian Cheek Balance
Title 24 Calci.
Plans picked up. Construction
Flood plain plan
Plans resubmitted Mechanical
Girding plan
2'! Rtvttw, ready for correctiew cau,c Electrical
Subcontactor List
Called Contact Person Piumblug
Grant Deed
Plans picked cep SALL
ILO.A. Approval
Plans - bmitted Gradtog
IN ROUSE:-
Review; ready for correctioasttaae Devdoper Impact Fee
Planning Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
IA
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
Vk"TANT! NOT IC Tn PR(TPERTY Om E�
Dear Property Owner.
An. application for a building permit has been submitted m* name listing yourself as the builder of the property
improvements specified at _, Z x z o 09lleivff—A-yecQ
We- are providing you with an Owner -Builder Acknowledgment and lnformatien Verification Form to make you aware of your
eespessibilities and possible risk you may incur by having this permit issued in your name as the
Owns -Builder. We will not ism a building permit Antil you have read, initiated your undersumding of each prevision,
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.
React ase¢ initial each statement below to signify you undersiarid or ver. ify this information.
1 I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
ding permit that erroneously implies that the property owner is providing his or her own labor and material personalty. 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 willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
00 my property -
.2. I understand building permits are not required to be signed by property owners unless they are responsible for the
"cton and are not hiring a Licensed Contractor to assume this responsibility.
I understand as an "Owner -Builder" I am the responsible party of record on the permit- I understand that I may protect
from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
uts.and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
y construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
F, state and federal law.
6. 1 understand if I am considered an "employee" under state and federal law, I must register with the state and federal
Inment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
sensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
7. 1 understand under California Contractors' StateLicense Law, an Owner -Builder who builds single-family residentia
s tunes cannot legally build them with the intent to offer them for sale, unless all work is performed by license(
bcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performe4
under contract with a licensed general building Contractor.
t
8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable, tu.
financial or personal. p; u m. sustained by any subsequent owner(s) that result from any latent construction defects in th.i
farty
ship or materials.
understand 1 may obtain more information regarding my obligations as an "employer' from the Internal. Revenue
the United States Small Business Administration, the California Department of Benefit Payments, and the California
of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSd� at 1-
CSLB (2752) or www.cslb.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
egally and �nan�ially rcWonsible . for roposed construction activity at the following address:
57 C eN r agree that, as the party legally and fwaacially responsible for this proposed construction activity, I will abide by all
le laws and requirements that govern Owner -Builders as well as employers.
12.1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information l
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 license,. bre Contractors' State License Board may be tmabie 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 civil Court- It is also
importa m for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while wotdciug
on your property: you may be Held liable for damages. If you obtain a permit as Owner -Builder and wt8h to hm Contractors,
you will be responsible for verifying wliether or not those Contractors are properly licensed and die status of dome wofkers'
coon ino mmoe 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 issuing tlhaeta: A copy of tha propertp owl's Mver's Reiff sei fm ft"w baHvn; or
other verification acceptable to theey I equimd to be press a 4 when die permil is in"4 to verify the property
owwner's signature.
Signature of property
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 I understand. is my personal responsibility, I hereby authorize
the following person(s) 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): Z e�Ne I s
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 abov(
information and certify its accuracy. Not :Acv of the owner's driver's license, form notarization, or other verification
acceptable to the agency is required toe pre Anted when the permit is issued to verify the property owner's signature.
Property Owner's Signature �� Date: ZG