13-0540 (ELEC)ii'..:.
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA; CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
Applicant:
13-00000540
52420 AVENIDA VELASCO
773-265-009-9. -000000-
ELECTRICAL.
COVE RESIDENTIAL
800
Architect or Engineer:
1 K
414
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
t he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031 .5 by -
Y pplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
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.).
l) 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
Fte:�
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 exemmj pt under Sec. , B.&P.C. f t reason
�(o Ownei!
UCTION LENDING AGENCY
I hereby affirm under penalty of perjury thWe'r. construction lending agency for the performance of the
work for which this permit is issued ISec. C.1.
Lender's Name: n
Lender's Address:
I,QPE RA11T
Owner:
JON 'LOUTSENHIZER
52420 AVENIDA VELASCO
LA QUINTA, CA 92253
(760)272-0951
Contractor:
Owner
VOICE (760)"777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/26/13
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 of the work for which this permit is issued, I shall not employ any
person in any manner so as t becomes ject to the workers' compensation laws of California,
and agree that, if I should b ome su ct to the workers" compensation provisions of Section
3700 of the Labor Code, 1 tall f ith comply with those provisions.
Ap " ant:,
WARNING: FAILURE TO SEC RE R OMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO RI INS ENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS 1$100,000). IN A 1 0 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 info atio correct. I agree to comply with all
city and county ordinances and state laws relating to building cons // ctio nd hereby authorize representatives
of h' county to �nStt upon the above-mentioned property for in 8cti purposes.
O,a:ees [[ �f/ Signature (Applicant or A
,10~
Application Number . . . . . 13'-00000540 .
Permit ELEC-SERVICE CHANGE
Additional desc .
Permit. Fee. .33. 50 Plan Check Fee..
.00
_
• Issue Date Valuation . .
. 0
Expiration` Date 10/23/13
Qty Unit Charge Per
Extension,
BASE, FEE
15.00
1.00 18.5000 EA ELEC SVC <=600V/<=200A
18.50••.
Special Notes and Comments
ELECRICAL PANEL CHANGE -OUT. 2010 CODES.
-- - - - - - - -_--------- - - - - --
Other.Fees BLDG STDS ADMIN (SB1473)
1.0.0,__.
Fee summary. Charged Paid. Credited
Due
Permit Fee Total 33.50 .00 .00
33.50
Plan Check Total .00 .00 .00
.00
Other Fee Total 1.00 .00 .00
1.00
Grand Total, 34.50 .00 .'00.
34.50-
LQPERMIT
Bin. #
City of La Quinta
BuMne 8r Safety Division
Permit #
P.O. Box 1504,78-495 Calle Tampico
�j
La.Quinta, CA 92253 - (760) 777-7012
Building
Permit Appiication and Tracking Sheet
ProjectAddress: Z Z�
` e /f CO Owner's Name:. c/��v Agafs piU z
A P. Number.
�''�//
Address: 5� % U/ I�7i Me -16 C D
Me-1
Legal Description:
City. ST, Zip. U may_
Contactor.
Telephone:
Address:
Project Description:
City, ST, zip:
/%//
�U;
Telephone:
S ��vic
State Lic. !i :
City Lie, f{
Arch.. &V., Designer.
Address:
City, ST. Zip:
Telephone:
Construction Type: may:
State Lia #:
Project type (eirde one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft : Stories:. A Unite:
Telephone #of Contact Person:
Estimated Value of Project �—
APPLICANT: DO NOT WRITE BELOW THIS LINE
A
Submittal
Req'd
Recd
TRA(1CIIVG PERMIT FEES
Plan Sets
Plan Check submitted heat Amount
Structural Calea
Reviewed, ready for twrrecdoas Plan Check Deposit,
Tress Glu.
Called Contact Person Pisa Check Balance.
Title 24 Cates.Plum
piekcd tip Cot;tt•actton
Flood plain plan
Plans resubmitted Mechanical
Gradlog plan
Z'! Review, ready for corr•ecdoWiissue Electrical
Subcostactor List
Called Contact Person Plumbing
Grant Deed
Plans picked up S,
U -0.A. Approval
Plans resabmitted Grading
IM HOUSE:.
Review, ready for correctionslitsue Developer Impact Fee
Phnniag Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit Issue
School Fees
Total Permit Fees
t�o`r i
P.O- BOX 1504
LA QUINTA; CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
i'
BUILDING & SAFETY DEPARTMENT
PROPER'T'Y OVM- R'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Formes for Owner-Bullders Applying for Construction Permits-
� � ! rtoHCF 10 PROPRTi� awl�r�,R
Dear Pwpaty Oi mtr:
Ari. application fvr a
Wilding Pmt been
sirbmitted in YOW name listing yourself as the badder of the property
in4movements specified at Z `-( 20 09yeAl t lelGriCQ
Mfe, are p%viding you with an Owner -Builder Acknowledgment a pd Information VaTkation, Form to make you aware .of your
reqmnsibilfties and %te risk you miY meas by hoing Ebispamit issuod lir your name ss the
Owner -Budder. VYe wal not issuea building -permit untilyaacliave read, bi'ddded your. Roderstanding of each•providon,
signed, and returned this form to us at our official address indicated. An agent of t1a owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
Read and initial each statement below to signify you understand or vea(fy this btformadm-
1. I understand. a frequent practice of unlicensed persons is to have the property owner obtain an -"Owner-Builder"
ding permit that arvneously implies that the property owner -is providing hisor her own labor anis material penKmak.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 anOwner-Builder and am aware of the limits of my insurance -coverage for injuries to workers
mY pY-
2. I understand building permits are not required to be signed by property owners. unless they are responsible for the
tion and are not hiring a licensed Contractor .to issume this responsibility.
ty-
3. I understand as an"Owner-Builder" I am the responsible. party -of record on the permit" 1 -understand that I may protect
If 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
As 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 tie considered an "employer"
T. state and federal law.
- 6. I understand) if I`a`d'coiisidi iced an "employer" under state and federal taw, I must register with the state and fedem
< vernment, vs�ithhold payroll taxes, provide woikers' compensation disability insurance; and: contribute to unemploymen
nsation For .each "employee:" I also understand my -fidure tv abide. by these laws :may subject me to serious-fi`n imia
' 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residenti.
stpwtures cannot legally build them with the intent to offer them for sale, unless all work is performed by license
bcontraetors and the number of structures does not exceed four within any calendar year, or all of the. work is performq
under contract with a licensed general building Contractor.
^ 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable. to,.
-i financial or persona l sinned by any subsequent owner(s) that result from any latent construction defects in th..
Z9rkmaaship or materials:
. I understand I may obtain more information regarding my obligations as an "employer" froom the Inert Rw*enue
fi
the United States Small Business Administration, the California Department of Benefit Payments, and the California
of Industrial Accidents. 1 also understand I may contact the California Contractors' State License Board (CSM at I-
CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
egally and bmncially responsible . for roposed construction activity at the following address:
L P� l 2 1 agree that, as the party legally and finaucially responsible for this proposed construction activity, I will abide by all
e 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, dete ions, or ch#nW to any of the ialbanation I
have provided on this form. Licensed contractors are regulated by taws designed to protect the public. If YOU e0idmct with
someone who does not have a lioww, _Flee Contractors' State License Board may be timable to assist you with MY financiat loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil OOWL It is also
impoetwK far you to: understand that if are mfliooesed Contractor or gv&yee of that individual or firm is injured whik worl=g
on your property; you may be hdd time for damages. If you obtain a permit as Owner -Builder and wise to hire Condors,
you will W respoosklo for ver&jring Wkthef or not those Comractors are pryopedy do mso and the status of.01W workers'
no tion insurance coverage.
Before a bWMing permit can be issued, fids form must be completed and signed by the property owner and retumed to
the agency responsible for isse�,.0w. ore: A copy of fldwpvperritowocr�'s dh1rer's fm ��h or
other verykaden acceptable so dieregrtie+aL to be presented when dopermit is issrn4 to v rtfy' dbs ProP"
owner's signature
sop ahem of property
Date: �6 r�
Note: 716e following Authorization Form is required to be completed by the property owner only when &$*hating
an agent of the property owner to apply for a construction permit for the Owner-
Builder—AUT
HORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHA —,F
Excluding the Notice to Property Owner, the ertegution of which i understand. is my personal responsibility, I hereby authorise
dm following person(s) to act as my ageat(s) to apply for, sign, and file the documents necessary to obtain.an Owner -Builder
Permit for my project. A,
Scope of Construction Project (or Description
_off Work): iUe e
Project Location or Address: ° ` r2MF (-�I'"% —
Name of Ikuthorized 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 1 personally filled out the abo-
information and certify its accuracy. Not .-A co of the owner's driver's License, form notarization, or other verification
acceptable to the agency is required tg e pre .rated when the permit is issued to verify the property owner's signature.
Property Owner's Signature�� Date:2t/