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13-0100 (ELEC)P.O., BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: Property Address: APN: Application description: Property Zoning: Application valuation: Applicant: 13-00000100 77125 CALLE TEMECULA - 774 -261 -007 -ST -000000- ELECTRICAL COVE RESIDENTIAL 200 BUILDING & SAFETY DEPARTMENT BUILDING PERMIT. Architect or Engineer: V./ ------------------ 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: Bl License No.: 550864 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 plicant for a permit subjects the applicant to a civil "penalty of not more than five hundred dollars 1$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.). 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 _;10, 1 property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.).. am exempt under Sec. , B.&P.C. for this reason " !/ / / CO STRUCTION 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: t LQPERMIT Owner: BILL KLAUSEN 57240 MERION LA QUINTA, CA 92253 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 1/31/13 Contractor: D ° BLS CONSTRUCTION INC 77-770 ROBIN ROAD PALM DESERT, CA -92211 (760) 275-9116 CITYOFILrAQUINITA Lic. No.: 550864 FINANCEJEPT ----------------------------------------------- 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 STATE. FUND Policy Number 465-0505690-12 1 certify that, in the performance of the work for which this permit is issued, 1 shall not employ any ' 4 �� 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 37 0 of the Labor -Code, I I forthwith comply with those provisions. . pp, cant: WARNING: FAILURE TO SECURE ORKERS' 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 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. 11 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 countyyto enter upon the above-mentioned propeA44Vspection purposes. - LQPERMIT Application Number 13-00000100 Permit . . . ELEC-MISCELLANEOUS Additional desc . Permit Fee . . . . 15.75. Plan Check Fee .00 Issue Date . . . . Valuation 0 Expiration•Date 7/30/13 Qty Unit -Charge Per Extension BASE FEE 15.00 1.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20 .75 Special Notes and Comments REPLACE MAIN BREAKER. 2010 CODES. --------------------------------------------------- Other Fees . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid' Credited --------------=------------------------- Due ---------=------- Permit Fee -Total 15.75 .00 .00 15.75. Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 16.75 .00 .00 16.75 f LQPERMIT Bin. # Perink # 13- ole Otk,of ' La Who BEAUng &I Safely Division P.O. Box 1504,78-495 Coe Tampico Li-QuInta, CA 92233 -:(760) 777-7012 Building Permit Applicadon'and Trackinz Sheet CA-Ite Trip owce,Nan,.Aj1 A- P.'Nurnbcr. ---------------------------------- Legal Description:. Contractor. C,&,Vi;rAV6riP?-I Address: I/V City, ST, Zip: -telphn �-tZ) 1, ;Ve"10R, Address: n -77o Project . Descr . iption: City,ST. Zip. 0 Telephone: StMUQ#:R C - Ity Cityu-- 4�- 'Arch, En &.,, Designer W-& Address-. Truss Cafes. City., ST, Zip: Teliphone: Name of Coafta Pawn: Eew,. ConMetion Type: Occupancy: Proled type (circle one): New MO. Alter Repair Demo I Sq. FL-. I# Stories. #.Units: Telephone 0 of Contact . P-rs,-:-7&,0 p9q 715 Est Estimalod VaWc of Project It 'APM IrA&M. r -.e% . N Submittal Plan Sets E"'d Etcc'd TRACING . Pfau Check submitted PEPJ4rrFEES- item Amount Struclurl! Cafes. Reviewed, ready for corrections Plan Check Deposit, Truss Cafes. Called Contact Person Plan Cheek Allan". Title 24 Calci. Plans picked up Constmcdon Flood plain plan Plans rcrubmitted Mechanical Grading plan 2*f Review, ready for corctetionsrmue Electrical Subcostattor List Called Contact Person Plumbing Grin Deed EIE] Plans picked up SALL ILO -k Approval Plans resubmitted Grading Ik HOUSE:- ------- Rlkvtewq ready for correctiondissuc Devclow Impact Fee Planning Approval. Called Contact Person AXP.Y- Pub. %Yke. Appr Date of permit issue School Fees Total Permit Fees P.O. Box 1504 LA QU[NTA, CALIFORNIA -92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 f BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Perm. is VkP0,81 ANT! NOTICIr Tn eRQPEDTY OWNEtt Dear Property Owner. Ari. application for a building permit has been sub miii your. name listing /� yourself t�he�huilder o€ the .property improvements specified' at /� t � Iq. � We are .providing you with an Owner -Builder Acknowledgment and- Information Veriftcatioa F rm to make you awarevf your responsibilities and possible risk you may incur by having this permit•issued in your name as :the Owner -Builder. We wi"U not issue a budding permit until you -have read, initialed your. understanding of each: provision, 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. OZ'S ACKN MEIDGIV)tENT AND VERIFIICATION OF I1ff OIb"T N DFItECTIONS: !lead and initial each statement below to -signify you understand`or veriff this ir�fornradon. 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" wilding permit that erroneously implies that the property owner is providing his. or her 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. 2. I understand building permits are not required to be signed by property owners unless they are responsible for the truetion and are not hiring a licensed Contractor to assume this responsibility..11A. 3. I understand as an "Owner -Builder" I am the responsible.party of record on the permit. I understand that I may protect yself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. *4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on pets and contracts. 5. I understand if I employ or otherwise engage any persons; other than California licensed Contractors, and the total value o my construction is at least five hundred dollars ($500), includinglabor and materials I may be considered an "employer" Y under state and federal law. 6. I understand if I am considered an "employer" under state and federal raw, I must register with the state and federal IJEKernment, withhold payroll taxes, provide workers' 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 /`7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential tures cannot .le all build -legally d 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. 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for 'any ancial or personal. igjudes sustained by any subsequent owner(s) that result from any latent constriction defects in the workmanship or materials. 9-I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue rvice, 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 1- 800-321-CSLB (2752) or www.cstb.ca.gov for more information about licensed contractors. /Vl0I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the . legally and financially responsible for proposed construction activity at the following address: O11. I agree that, as the party legally and financially responsible for this proposed construction activity, .1 will abide by all plicable laws and requirements that govern Owner=Builders as well as employers. Vv12.1 agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the information I e provided on this form. Licensed contractors are regulated by laws designed to protect he public. If you contract with someone who does not have a license,. the 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,6vil court. It is also important for you to: understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property; you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, You will be responsible for verifying whether= or not those Contractors are properly licensed and the status of their workers' compensation 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 issu€ttg; the.permit. Note: A copy of the property owner's d6ver'slfcensei form Aota�ativn; or other verification acceptable to the agency, is required to be presented when the permit is issued to verify the property owner's signature. 10� Signature of property owner 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 anOwner-Builder Permit for my project. Scope of Construction Project (or Description of Work):(/��}�r�/_,%�J�2 Project Location or Address: -V126' c farg,- Inje LA 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 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 requirW to a presented when the permit is issued to verify the property owner's signature.. Property Owner's Signature: Date: