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BPOL2015-020378-495 CALLE TAMPICO ' LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT BUILDING PERMIT 11111111111111111111 ,2 VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Application Number: BPOL2015-0203 Owner: Property Address: 54015 SOUTHERN HILLS CHANG ROBERDES APN: 775101061 54015 SOUTHERN HILLS Application Description: DEMO SPA AND REPLACE WITH NEW HOT TUB LA QUINTA, CA 92253 Property Zoning: a Application Valuation: $9,000.00 D Applicant:NOU `� 205 Contractor: , DAVID ROBERDES OWNER BUILDER 54015 SOUTHERN HILLS CIIYOFLi,QUINTA LA QUINTA, CA 92253 COMMUNITY DEVELOPMENTDEPARTMENT 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 Professions 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 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).: krisation, as owner of the property, or my employees with wages as their sole 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 hr she did not build or improve for the purpose of sale.). (yr I as owner of the property, am exclusively contracting with licensed contractors t onstruct 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 pursua Zontractors' State License Law.). I am exempt under Sec. . B.&P.C. for s r ason' Date: —� Owner: 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 Lender's Add Llc. No.: Date: 11/3/2015 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: 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-[ should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: Applicant: 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 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWLEDGEMENT IMPORTANT: Application is hereby made to the Building Official 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 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 city to enter upon the above-mentioned property for inspection purposes. Date: Signature (Applicant or Agent): Description: DEMO SPA AND REPLACE WITH NEW HOT TUB Type: POOL SubLype. SLaLUS. APPROVED Applied: 9/22/2015 MrA Approved: 11/2/2015 JFU Parcel No: 775101061 Site Address: 54015 SOUTHERN HILLS LA QUINTA,CA 92253 Subdivision: TR 22432-2 SEE ASSESSORS MB 769/43 Block: Lot: 6 Issued: FOR CMS STAFF NAME Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $9,000.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories:'O No. Unites: 0 10/9/2015 Details: DEMO EXISTING SPA AND ALL ASSOCIATED PLUMBING, ELECTRICAL LIGHTING, AND GUNITE. REPLACE WITH NEW HOT TUB ON NEW SLAB WITH NEW POWER PROVIDED. POOL MUST BE IN A NORMAL FUNCTIONING STATE AFTER PROJECT IS COMPLETE. 2013 CALIFORNIA BUILDING CODES. Printed: Tuesday, November 03, 2015 9:55:59 AM 1 of 3 SYSTEMS CHRONOLOGY =CHRONOLOGY TYPE STAFF NAME . - C.TION DATE COM._ PLETION DATE_ A TES . ° .. PLAN CHECK PICKED UP STEPHANIE GUMPERT 10/9/2015 10/9/2015 PICKED UP BY DAVID PLAN CHECK SUBMITTAL` MARY FASANO 9/23/2015 9/23/2015 RECEIVED DAVID ROBERDES SUBMITTED (3) SETS OF PLANS, (2) SETS OF RESUBMITTAL JAKE FUSON 10/30/2015 10/30/2015 STRUCTURAL CALCULATIONS AND (1) MANUFACTURERS SPECIFICATION BOOKLET. TELEPHONE CALL JAKE FUSON 10/1/2015 10/1/2015 NOTIFIED DAVID ROBERDES THAT PLAN REVIEW WAS COMPLETE AND REVISIONS WERE REQUIRED. TELEPHONE CALL JAKE FUSON 11/2/2015 11/2/2015 NOTIFIED DAVID ROBERDES THAT PLANS WERE APPROVED AND PERMIT WAS READY TO ISSUE. CONDITIONS Printed: Tuesday, November 03, 2015 9:55:59 AM 1 of 3 SYSTEMS Permit Details PERMIT NUMBER t City of La Quinta BPOL2015-0203 PARENTPROJECTS INFORMATIONFINANCIAL RETURNED STATUS " REMARKS REVIEW TYPE REVIEWER SENT DATE DUE DATE NOTES DATE. IST BLDG NS (1 WK) JAKE FUSON 9/23/2015 9/30/2015 CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # " CHECK # METHOD PAID BY BY BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00 11/3/15 R10495 5156 CHECK DAVID ROBERDES .SGU Total Paid for BUILDING STANDARDS ADMINISTRATION $1.00 $1.00 BSA: SWIMMING POOL/SPA 101-0000-42404 0. $181.29 $181.29 11/3/15 R10495 5156 CHECK DAVID ROBERDES SGU . SWIMMING POOL/SPA 101-0000-42600 �0 $98.62 $98.62 11/3/15 R10495 5156 CHECK DAVID ROBERDES SGU PC Total Paid for POOL / SPA: $279.91 $279.91 TOTALS::0 :0 PARENTPROJECTS RETURNED STATUS " REMARKS REVIEW TYPE REVIEWER SENT DATE DUE DATE NOTES DATE. IST BLDG NS (1 WK) JAKE FUSON 9/23/2015 9/30/2015 10/1/2015 REVISIONS REQUIRED SEE 1ST REVIEW. 2ND BLDG NS (1 JAKE FUSON 10/30/2015 11/3/2015 11/2/2015 APPROVED WK) BOND INFORMATION Printed: Tuesday, November 03, 2015 9:55:59 AM 2 of 3 SYS TEh1S Printed: Tuesday, November 03, 2015 9:55:59 AM 3 of 3 SYSTF. MS Bin # City of La Quinta Building 8z Safety Division 9 P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012. Building Permit Application and Tracking Sheet p roJect.Address; Q — ' I Owner's Name: I C�ICL n cz - --- `Qa+ �_ _�s Address: Q 1 �' i2 n* 14, A. P. Number: Legal Description: City, ST, Zip: Contractor: T hone: — ele P S 1 3 B C� Address: Project Description: City, ST, Zip: JP—M i ne- TeleP ho . t O 2 1 State Lie. # : City Lie. #; n Arch., Engr., Designer: Address: City., ST, Zip: Tele hone: Constructi n Type: Occupancy: aneY: 'State #: '(circle ct circle one : e Add'nto Al r Reair De Pr 'e typemo Name of Contact Person: '1 V4�4,Sq. Ft.: # Stories: # Units: Telephone # of Contact Person: —o3 �3 — S ` (D -T Estimated Value of Project: APPLICANT: DO NOT, WRITE BELOW THIS LINE 4 Submittal Req'd 12ec'd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calls. Reviewed, ready for corrections /� I Plan Check Deposit Truss Cates. Called Contact Person ' Plan Check Balance. Title 24 Cales. Plans picked up , Construction Flood plain plan Plans resubmitted 1 Mechanical Grading plan tad Review, ready for-corrections/issue 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 correctionsrissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue , School Fees ' Total Permit Fees P:'O. BOX 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT (760)777-7012 FAX (760) 777-7011 PROPERTY OWNER'S PACKAGE Disclosures & Forms for Owner -Builders Applying for Construction Permits IMPORTANT!_NOTICE TQ PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of 'the property improvements specified at �L{ Q (� 'S,c p � 2�-its �-.r.i`�c o t n 9 �. al 53' . We are providing you -'with an Owner -Builder Acknowledgment and Information verification Formtomake you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. •We will not issue a building 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: OWNERS ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DI REC TONS: Read and.initial each statement below to signs you understand or verify this information. -� 1 I understand a frequentpractice of unlicensed persons is to have the property owner obtain an "Owner -Builder" , building 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 unhcensed.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. ' L- 2: 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. s V 3. 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 4. I understand Contractors are required by law to be licensed and bonded in California and to.list their license numbers on permits and contracts. 'ZI 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. �/ 6. 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 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. t &4. 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. V--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 financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 9. I understand I may obtain more information regarding my•obligations as an."employer" from the Internal Revenue Service, 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- 8�00-3�21-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. Y 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party• le ally: andfinanc�ial) /• responsiblle fo proposed/ construction ctivity at the following address: SIT. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as.well as employers. L.'12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I 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, 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 civil 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 issuing the permit. Note:` A copy of the property 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. Signature of property owner/ Date: t `� ILS a.M04 LT-0iI TLJ �A 5D+ Note: The followving- � orization 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 necess to obtain an Owner -Builder Permit for my project. l / Scope of Construction Project (or Description of Work): �Gf _ ) S `� _Dlc-�R / Project Location or Address: , y St%u:kaQ \ t L IS ia d Aa, A—t-t )-a Name of Authorized Agent: 1 2 06.0—g -a ,Q„S Tel No Address of Authorized Agent: t;!;_34 d ts 2jt t`,�� 4 k l l(g . Cl TCS _ S3 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 P_�Presen!�l when Oe p5Rnit is issu' jto verify the property owners signature. Ai -27 1A] i� 419_�_!27169-8 l 1 r}l °� �� 0 304 d� d}� % O['9 A] Ail 42_tAlAl1 (; lI*) 02-598-44,11 (A:�) 02-598-4415 o T 2015 Id A] 8176.E Registered No. 2015-8176 dl o NOTARIAL CERTIFICATE ROBERDES CHANG AIE ----------- - ------------ ----- -------.------------------ ------ ----------==--------=- personally appeared before me and -- ------------------------- ----- . admitted his(her) :subscription,to the; o - L L M�o old �� o attached . --=------------- o ol � 7,1717 .t] o >a�' of a} 7p3 z}ol �}o� PROPERTY OWNER'S PACKAGE - Disclosures & Forms.for Owner -Builders' Applying for Construction Permits 201514, 019-V 04°� This is hereby attested on this 1 . 01 °1 o tl r4. 4th day of Sep. 2015 at this office. Name of the office`rc1nl�lil°i! b}o}� 7�1 0 o Ol a- o}T� AHN and KIM JOINT NOTARY'S OFFICE y A]. s o17-1 �o} z - Belong to Seoul Central., • �471 :RA] District Prosecutor's Office 0 A'd4 ffj X27} 69-8 Address of the office o "� 0 304 69 -8,2 -Ka Taepyung- hung-ku _ Seoul, Korea °Iril ssayyyl'`''''Sign e of the tar Public L mra aI9 0 YYfi'+ j 70 (Z �. 077 UN KIM I L -017111 _R]2011 -128 -toll 91 7joff has been.authorized by the 2012'4, 09V05-02 � TT ;g T,4 ° _�;iTE1 Minister of Justice, the Republic of 0 0 °1 °, -ter `z a� a 7,1 0 0,117 "I . Korea,, to act as. Notary. Public Since 5, Sep. 2012 Under Law No.2011-128. , 210mm A ^_Q - -