12-0934 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 12-00000934
Property Address: 52455 AVENIDA VALLEJO
APN: 773-262-021-10 -000000-
Application description: WALL/FENCE
Property Zoning: COVE RESIDENTIAL
Application valuation: 779,
Applicant:' Architect or En
PP op Architect 9
00
VO
FAX
ICE (760) 777-7012
4FAX (760) 777-7011
BUILDING & SAFETY DEPARTMENT � INSPECTIONS (760) 777-7153'
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
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
a: ypplicant 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
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
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. , B.&P.C. for this reason
Date:.?, `, 2 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 Name:
Lender's Address:
LQPERMIT
Owner:
GANDARA ANNETTE
52455. AVENIDA VALLEJO
LA QUINTA, CA 92253
(760)698-2346
Contractor:
owner
Date: 8/16/12
o a a
AUG172012
CITY OF LA QUINTA
FINANCE DEPT
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
3700 of the Labor C de, I shall forthwith compl with tho a p�rovissiionns�
Date: — 'b- l( 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 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 it 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 prop e for inspecti purpose . / % �-
�\
Date: d D -16 'I 'Signature (Applicant or Age 0:
Application Number . . . .12-00000934
Permit . . . WALL/FENCE PERMIT
Additional des_c .
Permit. Fee 21.00 Plan Check Fee
.00
Issue Date Valuation'
779 .
Expiration Date 2/12/13
Qty .Unit Charge Per
Extension
BASE FEE.
15.00
3.00 2.0000 HND BLDG 501-2,000
6.00
--------------------------------------------------------------------
Special Note`s and Comments
36 LN -FT X 5 FT HT BLOCK WALL PER CITY
STANDARDS &APPROVED •PLANS. 2010 CODES.
--------------------------------------------------------------
Other Fees . . . . BLDG STDS ADMIN (SB1473)
-----------
1.00
Fee summary Charged .. Paid Credited
Due
Permit Fee Total 21.00 .00 .00
.21.00
Plan Check Total .00 .00. .00
.00
Other Fee Total 1.00. .00 .00
1.00
_ Grand. Total 22.00 00 .00
22:00
-LQPERMIT
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P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPI:CO
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
1( f1RT ffT1 I�IQTICE TO PRQESKITX OWNER
Dear Property Owner-
An.
wnerAn. application for a building permit has been submitted rn your me nalisting yourself as the builder of the property
improvements specified at S 2, Lf S S Age rl l a o, \[k ((,-- C n Lo- G)(-) Lyd-o, ' Cc,(9 2Z S-3
We are praovidmg you with an Owner -Builder Acknowledgment and [nformaVerification ormF to make you awama o€ your
ceSpenstbilities and possible risk you may incur by having this permit issued in your name as .the
Owner -Builder. We will not ism a building permit until you-haave read, initialed your understanding of eadr'providon,
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 tkCIRN0?Rfii:E)'T AND-VERMCA.TION OF MFORMT ON
IJt4 ECYTONS: Read and Mitiat each statement below to signify you uicdw3tand or Verlythis Mformadon.
a)�b 1. I understand a frequent practice 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 pmsonak. 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 ami aware of the limits of my insurance coverage for injuries to workers
on my. Ply
a2. 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..
03. I understand as an "Owner -Builder" I am theresponsible 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.
�4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
0--05. 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 ,employee,
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
&47. I understand under California Contractors' State License Law, an Owner -Builder who builds single4amily 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 performer
under contract with a licensed general building Contractor.
N 4
&A8. 1 understand as an Owner -Builder if I sell the property for which this pertiut is issued, I may be held liable for any
financial or personal. uyaries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
W9. 1 understand I may obtain more information regarding my obligations as an "employee' 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-
800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors.
GA10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
Ply legally and finpciallly responsible for proposed construction activity at the following address:
5 a LA S 5 ouo ems o�(l-e ok is t-4 4 D L✓i�G C -c, 4'- 7= Z lf� 3 . .
.04 1. 1 agree that, as the party legally and fuiancially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions; deletions, or changes to any of the information I
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'civil court. It is also
important for you to: understand that if an unlicensed Contractor or employee of that individual or firm is injured wbile woddng
on your property, you may be held liable for dames. If you obtain a permit as Owner -Builder and wish to hire Coniraotors,
you will be responsAtle for verifying whether or not those Contractors are prepetiy licensed and the status of dwit 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 issuiteg.tke.perni t. Nota: A copy of rhe prop" owner's diivir's , fOm "44*86614 or
other verifwadon acceptable so the agency is required to be presented when the permit is ismed to verify the PMerfY
owner's signature.
Signature of property owner / (� ft / �KJ Date: Q L� -)Jo Jo Z
Note: The following Authorization Forts 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 AGLNT 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 pemon(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):
Project Location or Address:
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, forst 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
Property Owner's Signature: Date:
Dlll 11
City of La Quinta
Building &r Safety Division
Permit # P.O. Box'1504, 78-495 Calle Tampico
0M La Quinta, CA 922S3.(760) 777-7012
Building Permit APPlication and Tracking Sheet
X Project Address: ' a >f sA.
(� t� wner's Name: G
A. P. Number: a
T r
Address:�
Legal Description:
City, ST, Zip: LU. (� v 1 VL� C. �
Contractor: e q elephone: �6 0 6 (�8 ?-_5,
Address. �
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Z'-( S S Je n�d� a lle' Project Description:
-+� City. ST, Zip: L'a -CG- ZZs ?jt -
O+ 1 1 l a (1 aCvi- moi' O --I
Tele hone: 8 :(o:4
6
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�C State Lic. # : S
City Lic. #:
3)6 lam-\ V\ ea -r -( 2 et .
Arch., Engr., Designer: .
Address:
City, ST, Zip:
Telephone:
State
Construction ru
cti
onP•
Type:
Occupancy:
Lc. i
#
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Name of Contact Person: Pr
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type
(circle le
one): New
Add'n. Alter Repair Demo
a -n
Sq. Ft.: # Stories: # Units:
I Permit Fees
Amount
Telephone
# of Contact Person:' NoD ,(�
Estimated Value of Project: 0 Ate"
IS
APPLICANT: DO NOT WRITE BELOW
THIS LINE .
#
Submittal Req'd Recd TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Structural Calcs. Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs. Called Contact Person ' '
Plan Check Balance
Title 24 Calcs. Plans picked up
Construction
Flood plain plan Plans resubmitted
Mechanical
Grading plan 2°d Review, ready for corrections/issue
Electrical
Subcontactor List Called Contact Person
Plumbing
Grant Deed Plans picked up
SALL
L
H.O.A. Approval Plans resubmitted
Grading
IN HOUSE:- d'd Review, ready for corrections/issue Developer Impact Fee
Planning Approval Called Contact Person
A.I.P.P.
Pub. %Vks. Appr Date of permit issue
School Fees
I Permit Fees
Amount