12-1358 (ELEC)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 12-00001358
Property Address: 78845 LA PALMA DR
APN: 604-163-017-117 -23269 -
Application description: ELECTRICAL
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 200
Applicant: %
Td!t 4 4 Q"
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
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
LLicense 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).:
1 _ 1 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.).
(_ 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. , B.&P.C. for this reason
(D // /b /Z O
CONSTRUCTIO NDING AGENCY
I hereby affirm under penalty of perjury that there is a constr ion lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.). -
Lender's Name:
Lender's Address:
r`
LQPERMIT
r
Owner:
KUCHYT CHRISTOPHER
78845 LA PALMA DRIVE
LA QUINTA, CA 92253
(
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
11/16/12
*oy \
'0 l�?0,?
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 1 should become subject to the workers' compensation provisions of Section
3700 of the Labor Code H wit comply wi hose provisions.
Da� te•. '4ZApplicant:
n�
WARNING: FAILURE TO SECURE WORKERS' COMPENS ON COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES A CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO THE COST F COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
- f - - 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 state laws relating to building const et nd hereby authorize representatives
of this county to enter upon the above-mentioned property for i ecti s'
'Date:�_/�- � -&-gnature (Applicant or Agent):
t
Application Number . . . . . 12-00001358
Permit . . . ELEC-MISCELLANEOUS
Additional desc .
Permit Fee . . . 15.75 Plan Check Fee
3.94
Issue Date . . . . Valuation
0
Expiration Date 5/15/13
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20
.75
----------------------------------------------------------------------------
Special Notes and Comments
' ELECTRICAL LINE FROM HOUSE TO GAZEBO
100' GARAGE EXISTING BOX ONE OUTLET
(110V) COBALT PIPE & OUTDOOR ELECTRICAL
LINE 121UNDERGROUND.2010 CODES APPROVED
BY B.H.
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
----------------- ---------- ---------- ---------- -----
Due
-----
Permit Fee Total 15.75 .00 .00
1.5.75
Plan Check Total 3.94 .00 .00
3.94
Other Fee Total 1.00 .00 .00
1.00
Grand Total 20.69 .00 .00
20.69
LQPERMIT
PROPERTY UNE 60 P'
EXkSi iGVhFGii
wi000 FErvcF �,I
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X
ZU91LI111
P.O. BOX 1,504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY ONNER' S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
MOM
I I�IOTIC� T(1 RCiPBI�TY n��VNIIR
Dear Property owner.
An. aWheation for a building permit been submitted in your name listing f as the builder of the property
improvements stwified at ?8 4e,*, ,,� n� y � � s^ y
Wfe : Wovrdmg you w� an owner -Builder AckmWitkinent and Information Venfreation Form to make you aware of your
Etc and possible risk you may incur by havir!g thisperrmt.issuled in your mane as the
OWnM-Builder. We Will not issue a
bu1ding.permit wntll Y,04 -have read, Initialed yourundo-standing of each prevision,
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.
OVWWS AEeI6IV ? Rrr r1 H NT AND N f iT WN
DAWJ�. Read and prrtral each statwnmt& + tg sigmfy you understand or Va* dtis information.
G��=: I understand a freque°t Practice of unlicensed persons is tot hthe-property owner obtain "OB '
m
build
g perinit that erroneously implies
P gym' n an "Owner-uilde� lies that the property owner is providing his or her own labor and material personally. 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 working on my property. My homeowner's insurance may not provide coverage for those
injuries• 1 am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my property.
144— 1 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 respoumbility.
I le party of record on the permit. I understand that I may protect
understand as an "Owner Builder" I am the responsib
yself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
L4�IK. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
understand if I employ or otherwise engage any persons, other than California licensed Contractors and the
Of my construction is at least five hundred dollars (S500),including labor and materials, may be considered an "employer"
under state and federal law.
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 woi-kers' 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.
R1. 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 performer
under contract with a licensed general building Contractor.
Y
e8.I understand as an Owner -Builder if I sell the property for which this pernut is issued, 1 may be held liable for any
financial or personal. ionries steed by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
ix I understand I may obtain more information regarding my obligations as an "employee' from the b*crs l 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 (CRL13) at 1-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
AK0- I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party I ally and financially responsible for_proposed construction activity at the following address:
I agree that, as the party legally and fjnaociaUy responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owber-Builders as well at employers.
agree to notify the issuer of this form immediately of any additions; deletions, or dwnges to any of the infarmation I
have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
somoonE who does not have a license, the Contractors' State License Board may be tenable to sseist you with any 6naneW loss
You may sustain as a result of a complaint Your only remedy against unlicensed Contractors may be m'civd Court- It is also
important for YOU to understand that if an unhoonsbd Contractor oe entployee of that individual or firm is i>tjttrod while vrwkmg
on your property; you may be held lime for damages. If you obtain a permit as Owner -Builder and wish to hire Ccx►traebts,
you well be res MA& for verifYm Winibm or not those Contractors are pmpcdy livened and the status of their workers'
compensation insruanoe oovemp.
Before a building permit can be issued, this form must be completed and signed by the property owner and retained to
the agency responsible for NoW A copy of dw praperW awner's Mvw'vAVw0ttj fam MotaakadM or
other verification acceptable to dee sgeney is required to be presented when die pemtk is issueg to xarify the P
owner's signature. _
Signature of property ovrner
Date: //—/�o — /?—
Note:
Z
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 MHAL•F
Excluding the Notice to Property Owner, the txcWtion of which I understand is my personal responsibility, I hereby authorize
the following pemon(s) to act as my agents) 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, form notarization, or other verification
acceptable to the agency is required to be presiWed when the permit is issued to verify the property owner's signature.
Property Owner's Signature: Date:
Bin.#
City. 0f Ld Qulhtd
-BU11(11ng SL Safety Division
P.O. Box 1504,78-495 Caffe Tampico
La.Quinta, CA 92253 -:(760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: �` ��
Owner's Name:.
A. P. Number.
Address: %� 8� S`�s
Legal Description:
City, ST, Zip:
Contractor: i(lL�iL'
Telephone
Address: 4 j L �� J2 •
Project Description:
City, ST, Zip:�G%
Telephone:
P
rel: 4,., z<
Stats Lic. # :
City Lia #:
f '—'A
Qa °:
Arch., Engr., Designer.
Ue��A/4�C �X/f% /•{�� rys�
Address:
� . eari4$E9C� .f/E t%GTG2�1
City, ST, Zip:
Telephone:
State Lic. #: •; ,w, .r
j 'Name of Contact Person:
.�
Construction Type:. Occupancy
Project type (circle one): New Add'n Alter epair Demo
Sq. Ft.: # Stories: Units;
&BstiMN-47
_Telephone # of Contact Person` "" -
APPLICANT: DO NOT WRITE BELOW THIS UNE
k
Submittal
Rcq'd
Recd
TRACKING
PERMIT FEES'
Plan Sets
Plan Check submitted
Item Amount
Structural Calm
Reviewed, ready for corrections
Plan Check Deposit. .
Truss Calcs.
Called Contact Person
Plan Check Balance-
Tide 24 Calm
Plans picked up
Construction
Hood plain plan
Plans resubmitted..
Mecharilcal
Grading plan
2'r Review, ready for correctionsfcssue
Electrical
Subeontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S_yl,i
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'^' Review; ready for correctionsfissue
Developer Impact Fee
Planning Approval.
Called Contact Person
A.LP.P.
Pub. Wks. Appr
Date of permit issue
school Fees '
Total Permit Fees