09-0282 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA792253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:,'
Application valuation:
{
09'-00000282
51735 AVENIDA VALLEJO
773-131-026-12 -000000-
RE-'ROOF
COVE RESIDENTIAL
14000
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Applicant- 'Architect or Engineer: ,
LICENSED CONTRACTOR'S DECLARATION
hereby affirm under penalty of perjury that 1 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:
-- 9 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 (Chapter9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any�,Sppffcant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 155001.:
(_ 1 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 ISec. 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 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
property who builds or improves thereon, and who contracts -for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
( 1 I am exempt under Sec. or this r son
Date :• .Ow
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:
THOMAS TRACI
51735 AVENIDA VALLEJO
LA QUINTA, CA 92253
(760)699-3800
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/27/09
1
7--------_--------------------------------------
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 I should become subject to the workers' compensation provisions of Section
3790 Of the Lab I shall forthwith comply with those provisions.
Dat 2� I pplicant:
WARNING: FAILUR 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 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 information is correct. I agree to comply with all
city and county ordinances and st relating to building construction, and hereby authorize representatives
of this c unty t en r upon t abov ion -property for inspection purposes.
Dae:Signature t At ,
Application Number
09-00000282
Permit
RE -ROOF
Additional desc-
Permit Fee• .. ..
30.,0,0
Plan Check Fee
.00
Issue Date.
Valuation
0.
Expiration Date..
9/.23/09
- Qty Unit Charge
Per
Extension-'
BASE..FEE. -
30.00
Special Notes and
Comments
RE- ROOF CLASS "A"
MATERIALS .2-007
CODES
-- - - - - - - - - - - - - - - - - - - - -
Other Fees
- -- ---•---------------------------
BLDG STDS ADMIN.(SB1473)
1.00
Fee.summary
Charged
Paid Credited..
Due
---=-------------
--
---------------- ------------
Permit Fee•Total
30.00
.00 .00
30.00
Plan Check, - Total "
, .00 ,
.00 .00
00
Other Fee Total'-
1:.00
.00 ,00
1.00.
Grand Total•.
31"..00
.00 .00.
31.00
- ._ LQPERMIT
P.O. Box 1504
LA QUINTA, CALIFORNIA- 92247-1504
78-495 ,CALLETAMPtco
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760).777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction,Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An. application fora building permit has been submi ed in your name listings yourselfas the builder of, the ,property
improvements specified at. _T -t, %3� AA k �1e';6 A_ C ao* ,x- C'-► .
We are .providing you with an Owner -Builder Acknowledgment an In ormation Verification Form- to make 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.
OWNER'S ACIGNOWLEDGMENT APID'VERIFICATION OF INFORMATION '
F
CTIONS:"Read and initial each. statement below to signifyyou understand orverify this information.
.I understand a frequent practice of unlicensed persons is to have the propert} owner obtain an "Owner-Builderng 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 y property.
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..
C3. I understand as' an "Owner -Builder" Lam the responsible,party of record on the permit. I understand that I may protect
C3
from potential financial risk by hiring a licensed Contractor and having the permit filed in his°or her name instead of my
414. I understand Contractors are required by law to be licensed and bonded in California and to list their, license numbers on
permits and contracts.
�5. I 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 ,
,) 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, andcontribute 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
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.
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
4orkmanship or materials.
9. I understand 1 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-
80 -321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
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 legally and financially responsible for proposed construction activity at the following address:
agree that, as the party legally and financially responsible for this proposed construction activity, .l will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
l2. I agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the information 1
ave 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'eivil 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 Mver's I ensei 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: d
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 an Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work): >- Ae &9-T� A _AaL C,
Project Location or Address:
Name of Authorized Agent: 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 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:
Bin #
City of La Quinta
Building U Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: _ f� wner's Name
A. P. Number: Address
Legal Description: City, ST,Zip: 54 OIL- Loll,
Contractor: O4 f 4 U, Telephone: --9 q -`5,f bo "!
Address: Project Description:
City, ST, Zip:
Telephone:
State Lic. # :
City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone: Construction Type: Occupancy:
P cY:
State Lic. #: Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person: Estimated Value of Project: �)
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
- TRACKING PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount 40
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2id Review, ready for correctionsfissue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''d 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