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13-1235 (SPIN)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: Property Address: ' APN: Application description: Property Zoning: Application valuation: Applicant: J 13-00001235 77855 CALLE TAMPICO UNIT 4 773-075-013-2 -000000- SPECIAL INSPECTION VILLAGE COMMERCIAL 350 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. Li;e�/ns/e}Gll 11 License No.: Date:: d� �7 Contractor - O4 R -GUILE DER 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 toitsissuance, also requires the applicant for the - permit to file a signed statement that he or she is licensed. pursuant to the Provisionsofthe 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, 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, BusinessandProfessions 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.). .'kf-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.). 'Q/{(`�I am exempt under Sec. ., B.&P.C. for this reason � PP�� i 1I &te 0 I 7 CONST5,WTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance bf the work for which this permit is issued (Sec. 3097, Civ. C.). - Lender's Name: Lender's Address: LQPEI%AIIT Owner: ROBERT ENDRES 450 MAIN STREET OREGON CITY, OR 97045 (503)544-2494 Contractor: Owner <<: VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 10/03/13 OCT 941018 D CITY OF Lq 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 /j issued. . rhave and will maintain workers' compensation insurance, as required by Section 3700 of the Labor I. 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. Dat Applican r 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 1$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 personat whoserequest 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 actor 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 hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. �Daattee ) Signature (Applicant or Aygent): Application Number . . . . . 13-00001235 Permit . . . ELECTRICAL 2013 Additional desc 9 Permit Fee . . . . 23.83 Plan Check Fee .00 Issue Date Valuation . . . . 0 Expiration Date 4/01/14 i Qty Unit Charge Per Extension 1.00 23.8300 EA ELEC SERVICES 23.83 ---------------------------------------------------------------------------- Special Notes and Comments ELECTRICAL - CHANGE OUT BAD BREAKER. 2010 CALIFORNIA BUILDING STANDARDS. ---------------------------------------------------------------------------- Other Fees . . PERMIT ISSUANCE M/P/E 90.57 Fee summary Charged Paid Credited Due Permit Fee Total 23.83 .00 .00 23.83 Plan Check Total .00 .00 .00 ..00 Other Fee Total 90.57 .00 .00 90.57 Grand Total 114.40 .00 .00 114.40 LQPERMIT Qin # City of La Quinta 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 # �n ��/i,�C ,J, J J Project Address: g11,e �ci• wner'sName: 2 rt �y!ol;�cs A. P. Number: Address: X30 Ma/�12 S' Legal Description: City, ST, Zip: Contractor: Telephone: `fit{ `',r� Address: Project Description: City, ST, Zip: L I C Act n e T-,cLGI re CL.i z-,� -- Telephone: RIM.z:.z, F<• ��;, �' �' State Lic. # : City Lie. M Arch., Engr.; Designer. �r Address: Cit,, ST, zip: Telephone: State Lie. #: •G �• w `""'t.4:f �'• � � ��>.i$>�� .�x > Construction Type: Occupancy: Project type (circle one): New Add'n Alterci-pair Demo Sq. Ft.: # Stories: �q, # Units Name of Contact Person: r VL (1 Telephone. #;of Contact Person: %3 Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE tl Submittal Req'd Recd TRACMG PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Cala, Reviewed, ready for corrections Plan Chcck Deposit Truss Calces.Called Contact Person Plan Check Balance Title 24 Cala. 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 Pians picked up I1.O.A. Approval 'Plans resubmitted Grading IN HOUSE:- '" Revlew, ready for correctionsAssue Developer Impact Fee Pub. Wks. Appr Date of permit issue SchodiFees 57 e.ei3 $3 Total Permit Fees. P.O. BOX 1504 LA QUINTA, CALIFORNIA 9224 7-1 504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-7012 FAX (7.60) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits 1W—OR LYTr NOTICE TO PROPERTY OWNER Dear Property Owner; An application for a building permit has been submitted in your name listing yourself as the builder of the pmpeny improvements specified at _ -?-795-S.- ('4 fl e 1-41 /4 42z e -o # We are providing you with an•Own r -Builder Acknowledgmeat.AW lnfmtn Wn Verification F ran to make you avmc of your responsibilities and possible risk you may incur by halving this permit issued in your name as the Owner -Builder. We wffl not lure a building.permit until y" have read, i6itiatled your understanding of each provido4, 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. Read below to signify you ai nd srsiand. or verify &kis _-'1. I understand it frequent practice of unlicensed persons is to .have the property owner obtain an "Owner-Builde>" building pernrit'that erroneously implies that the property owner is providing his or Ter 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 my property. &. 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. A6lCsi. I understand as an "Owner -Builder" I am the responsible party of record on the permit. 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 instead of my own. 14. 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 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 law, I must register with the state and federal government, withhold payroll taxes, provide woftrs' 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. . 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. Ak I. understand as an Owner=Builder if UselI the property'for which this permit is .issued, 1 may be WA liable, for any financial or personalnjuries strstaiiteil by any subsequent owner(s) that result from any latent co nstroction defects .in the worlcm.Anship:or materials. A I understand I may obtain more information regarding my obligmiots, as an. "employee' from the Internal Revenue Service, the United States Small Business Administration, the.:California Dopa tmenl of Benefit Payments, and die California Division of Industrial Accidents. l also understand I may contact the California Contractors"State License Board (C L13.) at I- 800-321 -CSLB 800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. AltJO. 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: 1. I agree that, as the party legally and ftnamially responsible for this proposed construction activity, I will abide by all app feeble laws and requirements that goy em Owner -Builders as well as employers. agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the informatioir I have provided on this foruL Licensed 'contractors are regulated by laws designed to protect the public. If you contract* with someone who does not have a license, the Conttaotors' State License Board may be tunable to assist you with any fi ameki loss you may sustain as a result of a complaint Your only remedy against. unlicensed Contractors tray be in-avil court: It is also important for you to Understand that if an unlicensed Contractor or ewooyce of that individual or.ftrm is iujttrcd while wotidng on your property; You may be. held.liable for damagcs: If you obtain a permit as>.Owmx=Builth i and wish to ham Contractors, You will be responsNt for verifying vkht&tr or �W those: Contractors' a rem licensed and the: Status of their workers' P ply congxrtsation insurance 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 issuing,Jhe.,permiL Note. A copy of tke•property owmer's dtiver'sfibe rsei form natsd or other verification acceptable to the agency is required to be presented when die permit is issread to ra* the property owner's signature. Signature of property owner 17 C ' �'v �G�� 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. Excluding the Notice W Property Owner, the exeeption of which I undentand.is my'personal'responsibility, l hereby authorize the.fotlowirtg persons) to act asmy a$ent(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) _K� ba -,w, a dYeflelzLe�� Project Location or Address: 7 7 9 S S C4 �I� %at nye Name 'of Authorized Agent: ` Al k1a �d � of � Y Tel No 71� LI %� � .. S `/500 Address of Authorized Agent: %ck IJ -5--7 &7'1 e,_ 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- A 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: to- 3" � 3