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11-1179 (ELEC)P.O BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: "11-000011.79' Property Address: 55090 SHOAL CREEK APN: 775-142-013- - - Application description: ELECTRICAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 1100 Applicant: 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. License Class: License No.: Date: Contractor: OWNER -BUILDER DECLARATION 1 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).: (_) I, as owner of the property, or my employees with wages as their -sole compensation, will do the work, and 1-1 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-, 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 town owner of property who builds or improves thereon, and who contracts for the projects with a contractor(sl licensed ` pursuant to the Contractors' State License Law.). ' I—) I am exempt under Sec. B.&P.C. for this reason ,,'-Date: I ` Z' ZO ner• ' CONSTRUCTION LENDING 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: ROLAND SMITH 55090 SHOAL CREEK LA QUINTA, CA 92253 -------------------------- Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 11/02/11 ------------------ 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 to become subject to the workers''compensation laws of California, and agree that, if I="become subject to the worker ' compensation provisions of Section 3700 of the Labor Code I shatL forth wit co I with se provisions: - /Date: ` ?- 20 � plicant: 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 ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3,706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.. APPLICANT ACKNOWLEDGEMENT - IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth onthisapplication. 1 . Each person upon whose behalf this application is made, each person at whose request and for - whose benefit work is performed under or pursuant to any permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of LaQuinta, its officers, agents and employees for any actor omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 1180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to build' �co,,nstrcutclion , and hereby a orize representatives of this��e he above-mentioned grope y peion purposes. (Applicant or Agent):IcId Application Number . . . . . 11-00001179 Permit . . .. ELEC-SERVICE CHANGE INV FEE Additional.desc . Permit.Fee . . . . 67.00 Plan Check Fee .00 Issue Date Valuation 0 . Expiration Date 4/30/12 Qty Unit Charge Per Extension BASE FEE. 30.00 1.00 37..0000 EA ELEC SVC <=600V/<=200A 37.00 -- - - - - - - Special Notes and Comments ADD NEW 100 AMP LOAD CENTER LOCATED IN GARAGE. 2010 CODES: WORK DONE WITHOUT HOA APPROVAL. INVESTIGATION FEE ASSESSED PER 1997 UNIFORM ADMINISTRATIVE CODE •§304.5 FOR WORK BEGUN WITHOUT BUILDING PERMIT. -------------------------------------------------------------- Other Fees . . . . . . . BLDG STDS ADMIN ($B1473) -- 1.00 Fee summary Charged Paid Credited. Due ----------------- ---------- Permit Fee Total 67.00 .00 .00 67.00 Plan Check Total 00 00 .00 .00 Other Fee Total 1.00 00. :00 1.00 Grand Total 68.00 ..00 .00 68.00 Bin city �f La.QutnLA Building &r Safety Division P.O. Box 1504, 78-495 Calletampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application aW Tracking Sheet Permit #. Project Address: -SS D S ems } (D12.-� . Owner's Name: A. P. Number: Address: S Legal Description: Contractor:' 6 V (..� � � � C City, ST, Zip: ark Telephone: •�r<::..r.;..;;.. •:.>„<c:.i:;;K:;:lei• Address: Project Description: City, ST, Zip: ©o u::ii •.>• Telephone: � .: ri<<:::#::;:>::z>:%:««<�:<;>:� State Lic. # : City Lia #: Arch., Engr., Designer: � Address: City., ST, Zip: p }v`i:AvT:i[:iti':i v:[:i\'�i:ii::i t•kWi4�: Telephone: :.>:::,;•;>:<:. ;;;:.:::;..:...+.fi.. P State Lic. #: x`< 'fr ;•ks:;;:; ;:.t:>:>:<s<cfi Name of Contact Person: Construction Type: Occupancy: Project type circle one • New Add'n Alter. Re air Demo Sq. Ft.: # Stories: # Units: Telephone # of Contact Person: Estimated Value of Project: 63 APPLICANT: DO NOT WRITE BELOW THIS ONE # Submittal Req'd Recd TRACKING PERMTT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Tithe 24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan V Review, ready for correctionstissue 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 corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees !oo P.O.' BOX 1504 LA QUINTA, CALtFORNIA.92247-1504 BUILDING & SAFETY DEPARTMENT 78-495 CAL LE TAMPICO (760) 777-7012 LA QUINTA, CALIFORNIA_92253 FAX (760) 777-7011 PROPERTY OVMER' S PACKAGE Disclosures & Forms for Owner -Builders Applying for Construction Permits " I NOTICE TO ROPfiRTY OWNER Dear Property Owner. Ag .application for a b your name listing yourself as the builder of the property building Permit has been submitted in inoprOvemmts specified at We are providing you with an Owner -Builder Acknowledgment and Information Verification Forte to make you avams of your resPetnsibilities andposSble risk you may incur by halving otis permit issued in your name as .the Owner -Builder. We Will not issue a bailding.pcenat until You have read, initiated your understaading of eaek'rvisbn, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this no,ace unless you, the Property owner, obtain the prior approval of the permitting authority- QMNIES AeINOWLEI GMENT AND YERMC"A`k'iON OF RWORMMN LTMUI70NS. Read and initial e+a& statMeru-beiow w signify you. urul+erstand or vetty flees Konnadon. @�1. I understand a fiiequent practice of unlicensed Persons is to have the property owner obtain an "Owner -Bader" ding permit that erroneously implies that the property owner is providing his or her own labor anis material permnalilr-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 woricing on my property.My homeowner's insurance may not provide coverage for Jose injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurancecoverage for injuries to workers on my property. `_2. I understand building permits are not required to be signed by property owners unless they are respoasible for the construction and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner -Builder', I am the resp' busible party of rword 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. . I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers o permits and contracts. L)65. I understand if I employ or otherwise engage an ns other than California licensed Contractors, and the tool vale of my construction is at least five hundred dollars ($500),.luding labor and materials, [ may be considered an `employe under state and federal law. 6. 1 understand if I am considered an "employee" under state and fbderal law, I must register with the state anc We government, withhold payroll taxes, provide woi kers'.. compensation disability insurance, and contribute to unemploymr compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious '"inane risk. '7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residen structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licen subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perfon under contract with a licensed general building Contractor. 1k8. 1 understand as an Owner -Builder, if I sell the property for which ibis P=Mt is issued, I. may be held liable for any ancia.l or personal. inm.tustained. by any subsequent owner(s) that result from any latent constriction defects in the worlananship or materials: 9 I understand:I may obtain more, information regarding my obligations:as an "employee.. from the Internal Revenua, "Service, the Unit and the California United States Small Business Administration, the California Department of Benefit Payments. Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 800-321-CSLB (2M) or www.csth.ca.gov for more information about licensed contractors. W10. 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 addr=s: 1 I. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and uirements that oven Owner -Builders as well as to req g employers. 12.1 agree to notify the issuer of this form immediately of any additions, deletions, or to any of the informatics I have provided on this form.. Licensed contractors. are regulated by taws designed to protect the public. If you contract with someone who does not have a lie mw, the Contractors' State License Board may be unable to assrist you with any financial km You may sustain as a result of a complaint, Your only remedy against unlicensed Contractors may be in'civil• court- It is also important for you te, understand that if an unh timed Contractor or employee of that individual or firm is injured while worldng on your property, You may be heU li" for damages. If you obtain a permit as Owm-Budder and Wish to hire Contracbrs, you will be res mwklo for v vs air not those Contractors are pmpcdy licensed and the SWUM of the Wotlaers' oortion iasuranoe 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 issuAft.dievermiL lYotc: A copy of tkc pmperq* owner's dtrer's Akwtsci fes'MtadMOM Or other verification acceptabk to the agency U "wised to be presented when dte pmtgit is i to verify the pro?" owner's signature. 1► �e . e e e e.y a I`1.6i,.E�—J—�L���I/. 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 conduction permit for the Owner -Builder. AWRORZATION OF AGENT TO ACTON PROPERTY OWNEWS BMLL— Excluding.the Notice to Property Owner, the ea OCM6on of which I understand is my personal responsibility, I hereby au&orize the following peraon(s} to act as my ogent(s) to apply for, sign,. and file the documents necessary to obtain an Owner -Mi -Mer Permit for MY project - Scope of Construction Project (or Description of Work): (v Av 70 4 44 p z.z a Su At Project Location or Address: .55)gQ G:4-0 4L Name of Authorized Agent: • LJO N �'% o VL R ELfe- l � Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the ab 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 requ' to be presented whop the permit is issued to verify the property owner's signature.. Property Owner's Signature: Date: 1 [ — Z ZOl 1 _ CITY OF LA QUINTA SUB -CONTRACTOR LIST JOB ADDRESS 55'U. U PERMIT NUMBER /I --/I 7q , . OWNER BUILDER This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance of building permit. For each: applicable trade, all information requested below must be completed by applicant. °On File" is not an acceptable response: Trade / Classification Contractor „ ::> .• . , . State:Contractor.s lucense Workers Co .:.. ensation insurance Ci.:.: Busin¢ss License Company Name Classification (e.g. A, B, C-8) License Number (xxxxxx) Exp. Date (xx/xx/xx) Carrier Name (e.g. State Fund, CalComp) . Policy Number (Format Varies) Exp. Date (xx/xx/xx) License Number (xxxx) Exp. Date (xx/xx/xx) EARTHWORK (C-12) CONCRETE (C=8) :FRAMING (C-5) . STRUCT. STEEL (C=51) MASONRY (C-29.) PLUMBING (C-36) .LATH, PLASTER (C-35) ` :DRYWALL (C-9) ' HVAC (C-20) ELECTRICAL (C-10) 640 pc�Ql�6 �� /3 �.fv�. 1390 4-s !z ROOFING (C-39) :SHEET METAL (C-43) FLOORING (C-15) .GLAZING. (C-17) INSULATION: (C72) SE=WAGE D1.SP. (C-42) PAINTING (C-33) CERAMIC TILE (C-54) CABINETS (C-6) t FENCING (C-1'3) r LANDSCAPING (C=27) POOL (C-53) Z a