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12-1007 (BLCK)4 P.O. BOX 1504 " VOICE (760) 7 7-7012 78-495 CALLE TAMPICO FAX (760) 777- LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 8/31/12 Application Number: 12-00001007 Owner: Property Address: 54550 AVENIDA DIAZ RASCH HOWARD APN: 774-271-003-22 -000000- 54550 AVENIDA DIAZ Application description: WALL/FENCE LA QUINTA, CA 92253 Property Zoning: COVE RESIDENTIAL --------------------------------- Application valuation: 230 Contractor: Pf Applicant: Architect or Engineer: Owner--------------------------- AUG 312012 CITY OF LA QUINTA FINANCE DEPT ' 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 an applicant 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 compensatiori, will do the work, and the structure is not intended or offered for sale (Sec. 70,44, 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 Atruct the project (Sec. 7044, Business and Professions ode: The Contractors' State License Law does n t apply to Tnner of property who builds or improves t ereon,andwhocontracts for the p 'jE s w'ih contractonsed pursuant to the Contractors' State License Law.). (_ 1 I am exempt under Sec. g, B &P.C. for this reason CONSTRUCTION ENDING AGENCY I hereby affirm under penalty of perjur thatr here is a constructs n lending agency for the performance of the work for which this permit is issued (S c. 3097, Civ. C.). Lender's Name: Lender's Address: LQPERMIT 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 issuedy workers' compensation insurance carrier and policy number are: Carrier Policy Number ' I certify that, in the perfdr once of the work for which this p mi is issue I shall not empl a�iy person in any manner s as to become subject to w (t r compensation laws of C ifor ia, and agree that, if I ho Id become subject to th ik comp siition provisions of a tion - / v 3700 of the. Co I shat) forthwith com y it those `pr•v'Iio uqv �I� ( A cant: I r r W/ WARNING: FAIL RE TO SECU W RKERS' COMPENSA ON COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TOC IMINAL PENALTIES AND C IL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,0001 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 fallowing issuance of this permit. 2. Any permit issued as a result of this applicati n becomes null and void if work is notL within 180 days from date of issuance of s ch permit, or cessation of 6foOpermitto cancellation. I certify that I have read this application and state that th above information is orrecity and county ordinances and state laws relating to uil ing construction, an h,re of/.. thi Abuniy to entjrjjpon th ove-mentioned pr e y for ins ecti pur S. aa'l teI/S' ture (Applicant or Agent): Application Number . . . . . 12-00001007 Permit . . . WALL/FENCE PERMIT . Additional desc . Permit Fee . . . . 15.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 230 Expiration Date 2/27/13 Qty Unit Charge Per Extension. BASE FEE 15.00 ---------------------------------------------------------------------------- Special Notes and Comments 24-30 L.F. OF -3.5' HIGH SPLIT RAIL FENCING AT FRONT PROPERTY AREA TO CLOSE CODE CASE # 12-2292. ---------------------------------------------------------------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1..00 Fee summary Charged Paid Credited Due Permit Fee Total 15.00 .00 .00 15.00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 16.00 .00 .00 16.00 LQPERMIT OVA a / I P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT - PROPERTY OWNEWS PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits MW&TANTI NO. IC>F Tn punrT�T� OW�� ©ear Property owner An. application for a buddin r eats% permit has sub 'n your listing yourself as C/�d S f Z .pro erty -imp specified at 3` U. 1 ' . IA Z IJ /U We am prtrwdmg you with an Owner -Builder AclenoWledgment and information Verification For to make you av+r= of your sibilities and Possible risk -you may incur by having thispermit-issued in your name as .the Ownea-Builder. We will not ism a building. permit until you�have read, initialed your understanding of each'preAsion, 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. Read and aritiaf each: swwrentbeho tb signify you adderstand or very this irtformafion. V.J understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" buil ing permit that erroneously implies that the property owner is providing his. or her own labor and material personale ji.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 - m1unes. I am willfully acting as an Owner -Builder and air aware of the limits of my insurance coverage for injuries to workers on my property. 1 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. L1�14- I understand as an "Owner -Builder" I am the responsi6le 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. A�4_I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on pernuts and contracts. 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. Ak�- 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 rislL �'9_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 fourwithin any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 9— L. 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. iro.tuies sugrained by any subsequent owner(s) that result from any latent construction defects in the oriananship or materials. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Sniall 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 (MR) at 1- 800- 21-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. Vp10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the I ally and fin='ally responsible r pro po�sed construction activity at the following address: ,RL, NI I agree that, as the party legally and financially responsible for this proposed construction activity,.1 will abide by all applicable lbws and requirements that govern fawner -Builders as well aS employers. "2. 1 agree to notify the issuer of this form immediately of any additions; deletions, or chsan$es 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 amY dial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may lie in'oivil court It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is i*ucd wbile working on your property, you may be held Liable for damages. If you obtain a permit as Owner -Builder and wish to him Contaectors, you will be respom&te fgr verlpymg v&etiter air not .thorn Contractors are prbpedy Cieemsed and the status of their wort 0W compensation insuranve coverage. Before a building permit can be issued, this form must be complet and signed by the property owner and returned to the agency responsible for is ta.psrmit. Nota: A copy of Ow J �r pen!" owner's dWveesI4wftM fWm nota dm or other verification acceptable the agsney is required to b prey;rl, a permit is Rued to v�(y lire property owner's signature. I Signature of property owner c ate: 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 BEHnF 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 necessarjr 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 drivers license, form notarization, or other verification acceptable to the agency is required !o be presented when the permit is issued to verify the property owner's signature - Property Owner's Signature: Date: x 6"J f Btn. Qty. of La Quifhtd Bulldlrlg 8T Safety Ditdsion P.O. Box 1504,'78-495 Calle Tampico U.Qulnta, CA 92253 - (760) 777-7012 Building Pe 't Application' and Tracking Sheet Permit # ProjectAddress: J S� T��� . %l9 Owher'sName:. t A jI�SC'jf A. P. Number Address: �' �� f , Legal Description: City, ST, Zip: G �. Q V T Cya Ct2—F-3 Telephone: ( Project Description: Contractor. 6 ( f t.% A Address: f — . r f�0 flv €, {� f �� City, ST, Zip: � ` `1 / /l% %%� CA C! Z 2fJTelephoner // I.YO- ,f_G — 3 3 City Lie*. #: State Lic. # : Arch., Engr., Designer. Address: Cortsttudion Type Occupancy: City., ST, Zip: Telephone: MEMO i' State Lic. #: wj : ; �. Name of Contact Person:Sq. project type (circle one): New Add'n Alter Repan Demo Ft.: # Stories: # Unit;: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Ree'd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount S"ctufal Calls. Reviewed, ready for corrections Plan Check Deposit. Truss Cates. Called Contact Person Plan Check Balance. Title 24 Calci. Plans picked up Construction Flood plain plan Plans resubmitted Meclhaiiical Grading plan 2'6 Review, ready for correctionsrissue Electrical Subcoutattor List Called ContactPerson Plumbing Grant Deed Plans picked up S.M.L H.O.A. Approval Plans resubmitted Grading IN HOUSE-, ''" Review; ready for correetiondissue Developer Impact Fee Planning Approval. Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees