11-1105 (PLBG)ly O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Iiii
S L ms" , F.
Application Number:
11-00001105
Property Address:
77805 CALLE DURANGO
APN:
773-232-001-22 -000000-
Application description:
PLUMBING
Property Zoning:
COVE RESIDENTIAL
Application valuation:
5000
Applicant: Architect
BUILDING & SAFETY DEPARTMENT.
BUILDING PERMIT
Owner:
DIAZ MIGUEL
77805 CALLE DURANG
LA QUINTA, CA 9225110 ,�J
Contractor:
Owner .
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/07/11
OCT on�.—
Ty
QF LA iw
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of.perjury.that I am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty, of perjury one: of the following declarations:
Section 7000) of Division '3 of the:Business and Professionals Code, and my License'is in full force and effect.
_ I have and will.maintain a certificate of consent'to self -insure for workers' compensation; as provided
License Class: License No.:
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued'
Date: Contractor:
_ I have:and will maintain workers' compensation Insurance, as required by Section 3700 of the Leboi-
Code. for the performance of the work for which this permit is,issued. My workers' compensation'
OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that 1 am exempt'from the Contractor's State License Law for the
Carrier -----------------------Policy Number
following reason (Sec: 7031.5, Business.and Professions Code: Any city or county that requires a permit to
_ I certify that, In the performance of the work for which this permit Is issued, -1 shall not employ any
construct, alter, improve, demolish, or repair any structure; prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws. of California,
permit to file a signed.statement that he or she is licensed pursuant .to the provisions of the Contractor's State
and agree that, if'I sh Id Deco subject tot kers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of DWision:3_of.the Business. and Professions Code) or,
3700 of the LaborC e, I I with c ly those provisions.
that he'or sit s;exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any a t.fora permit subjects the applicant to a civil penalty of not more then five hundred.dollare (95001.:
�,. ��
Dater r /—fI/Applicant:
(_ 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.oroffered for sale (Sec. 7044; Business and Professions Code: The
WARNING: FAILURE TO SECURE W K S' COMP NSA ION COVERAG UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or Improves'thereon,
SUBJECT AN EMPLOYER TO CRIMI AL PENALTIES D CIVIL FINES UPI, ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS RHOVIDED FOR IN
improvements are not intended or offered for sale. If, however, thebuilding or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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,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
propertywho builds or improves thereon;.and who contracts,for the projects.with a coritrartor(s) licensed
pursuant to the Contractors' Statelicerae Law.).
1 am exempt under,.Sec. , 11.11P.C. forthjs reason
Date: �/Q " % Z OF-# Owner: e
0AISTRUCTION LENDING AGENCY /
I herebyaffirm under penaltyof perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Chrc,C.).
Lender's Name: -
Lender's Address:
L.QPERMIT
APPLICANT'ACKNOW LEDGE.MENT
IMPORTANT Application is hereby made to the Director of Build Ing 'and Safety fora permit -subject to the
conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person atwhose request and for
whose benefit work is performed under, or pursuant to any permit Issued as a resuit of this application;
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the.City
of la Quints, 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 thWapplication becomesnull 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 torr �I to comply With all
city and county ordinancesiand,state laws relating to building co, tion, and eb a horize pIrematives
of this county to enteruponthe above-mentioned props for i ion pur
Dste:.� l ifature (Applicant or Agent):
Application Number . . . 11-00001105
Permit. . .
. PLUMBING SEWER.
Additional desc
.
Permit Fee
30.00
Plan Check Fee
.00
Issue Date . .
.
Valuation . . .
. 5000
Expiration Date
4/04/12
Qty Unit Charge Per
Extension
BASE FEE
30.00
-----------------------------------------------------
•Special Notes and
Comments
--------------
SEPTIC ABANDONMENT
/ SEWER HOOK UP.
--------------------- ----------------------------------------------------------------
Other Fees .
. . . . . .. BLDG STDS ADMIN. (SB1473)-
1.00
Fee summary
---------------
Charged Paid
----------
Credited
Due
--
Permit Fee Total.
----------
30.0.0
--------------------
.00 .00
30.00
Plan Check'Total
.00
.00 .00
.00
Other Fee Total
1.0.0
.00 .00
.1.00
Grand Total
31.00
.00 .00
31.00
LQPRRM[T
F
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P.O. BOX 1504
LA QUINTA; CALIFORNIA 92247-1504
79-495 CALLETAMPICO
LA QUINTA, CALIFORNIA 9225.3
BUILDING & SAFETY DEPARTMENT
PROPERTY O VIER' S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
'! I�tUTfCE 'PO PA(IPEM (iE
Dear P"paty O9vna:
An. application for a big permit has boon rA mitied in your name lisfft yomsdf as the builder of &e property
I specified at
We are peoviding you with an Owner -Builder Acknowledgment and Iafotmatien Vaification Form to moire 7m awatae of your
mobilities and posSble risk you may incur by burin$ this pert tawd in your tame as the
Owaes-+Builder. We WW not ince a Widing.peruH until you leave read, iliiwllalud your each Pteden,
signed, and returned this form to us.at our otncial address indicated. An agent of the owner cannot earecu t lis notice
unless you, -the property owner, obtain the°prior approval of the permitting authority.
Df WCT701YS. stead wW adtiat Back statcenew below to signify you wodwstiand or ver#ydw mfonnaWm
Z-1. understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Buddet"
building permit that erroneously implies that the property owner is providing his or her own labor and material PMW&fiy- 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 .
o=1understand
building permits are not required to be signed byproperty owners unless they are responsible for the
construc ' and ate not hiring a licensed Contractor to assume this responsibility.
- I protect
3. I understand as an `Owner Huilde:Y" I am tkte responsible party of raoord on the permit. I understand that may
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. I understand°Contractors are required b law to and bonded in California and to list their license numbers on
requ y be licensed
permits and contracts.
—6/1nderstand if I employ or otherwise engage any persons, other than.California licensed Contractors, and the total valve
of my construction is at., least five hundred dollars ($500), including libor.and materials, I may be Considered an "employee
under s to and federal law.
I understand if I am considered .an "employee" under state and federal law, I must register with the state and feder
govettunent, withhold payroll taxes, provide w0dws' compensation disability in urawe, and contribute to unemployma
compensation for. each "employee." I also understand my failure to abide by these laws may subject me to serious ftnanci
tisk.
7. I understand under California Contractors' State License; Law, an. Owner -Builder who builds single-family resident
structures cannot -legally build them with the intent to offer them for sale, unless all work is performed by hcens
subcontractors and the number of structures does not exceed four within any calendarr year, or all of the work is perform
under contract with.a licensed general building Contractor.
t ✓ - l understand m an Owner -Builder if I sell the property for which this permit is issued, I may be. held liable for any
financial or personal il*ries awed by any subsequent ownen(s) tient_ result from any latent construction defects, in the
woricm m
or aterials
understand -I may obtain more information regarding my obligations as an empbyer' from'the
Service, the United States Small Business Administration, the Califonoia Department of Benefit Paymensa, and the. California
Division of Industrial Accidents. I also understand I may contact the .California Contractors' Stat, License Bowd.(C MZ) at I-
800-3�21-CSLB (2752) or www.csib.ca.gov for more information about lieensed contractors.
`� l0. 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 financially- responsible for proposed - construction activity at the following address:
-,Z1.1- I agree that, as the partylegally and financially responsible for this proposed construction activity, I will abide by all
app7171
e and requirements that govern Owner -Builders as well as employes.
agree to notify. the issuer of &b fond► immediately of any additions; deletions, or cbeogea to any of the information 1
have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If YM eortraax'with
someone who does not have a li®emo, the Coettsators'State. License Board maybe°unable to ar dd you with any Elnancird loan
you may sustain as a result of a complaint. Your only remedy agauat unlicensed Contractors may be in civil court. It is also
for you talanderstend,duftif an noIicenW Contractor or employee of that individual oc tli!m is injured wlsle woddog
on YQUrVMPCftY; YOU may be h d li" for dames. If you obtain a permit as C1wna=Buffer and wilt to bin CONUMIUM,
you will be rho for veripligg mba&w or sat those Conaractors am.pmpcft_h ad 410 adds of then worters'
eosapaosation iwuanee, covw*e.
Before a building permit can be issued, tWs form must be completed sod signed by the property owner aad'retarned to
the agency responsible for iasa ft.00-I - tmII Note: A cepy I of tyre provery owner's +''s Awasgo fffm N66MkId'"', or .
other venyleadon aecapWde to dke agency is nquIV ad -to be pr wented when tine pgmk is to m* the pqwV
owner's signature.
Signauut of property owrner04
0
Date.
Note: Tare 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 conduction permit for the Owner -Builder.
Excluding the Notice to Property Owner, the excwtion of which I understand is my personal responsibility, I lrerebyauthorize
the foiiowring persoe(s) to act as my ageogs) to applyfor, sign, and file the documents necessaeyt+o 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 alio
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 signaWv-
PropertyOwner's ;'Signature- Date:
760-568-1789
09:41:04 a.m. 10-07-2011
•
,s
vyi
COACHELLA VALLEY WATER DISTRICT
t." P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651
INVOICE Date: 10/3/2011
SUBJECT: 77805 CALLE DURANGO, LA QUINTA, LID 683356,"SCC FEE ONLY"'
MIGUEL RUIZ Project: 11-3187
74869 JONI DRIVE, SUITE B Project Date: 10/3/2011
Amount. Due: $4;231'.00
PALM DESERT, CA 92260 GEO: 06-06-12-1
Planner: SANDRA VILLALOBOS
TO INSURE PROPER CREDIT, PLEASE RETURN THIS,PORTIONWITH
REMITTANCE AND INCLUDE THE PROJECT ON YOUR CHECK
SUBJECT: 77805 CALLE DURANGO, LA QUINTA, LID 683356,'SCC:FEE ONLY'
COACHELLA VALLEY WATER DISTRICT
P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651 Pagel
Permit #
Project Add"'
aty of U Q,. urnta
Balft ar Safety DMWm
P.O Box 1504,78-495 Calle Tampko
4.Quinta, CA 92253 - (760) 777-7012
Building Permit Application and'Tracking Sheet
Owner's Nemo i92 -
A P. Number:
Address:
Legal don:
City, ST, Zip. 'a (,
Contractor.
Addrem:
Telephone: V
/•PcojegDcmiption:77
city. ST, Zip: �)
Telepho rj60 ��aj-0'/3y: •
State Lia #:
AmhF Bogle, Dealgaw.
Mires
City, ST, 4:
Telephone:
State Lia #:
Name of Coma Person:
Construction Type: 0060pmcy:
Project type (an+de one): New Add'a Abet Repair Demo
Sq. FL: U
#'Stories: #Unites
Telephone i of Contact Person
r 8nt+mltWl 'a
Batlmabod value of Piojec t f p
APPLICANT: DO -RIOT WRIT BELOW, THIS UNE.
laee'a -. TEAMING PROW FEES,
Plan Seb
Pian check sabmiaed item Anoaat
Seracctarat Cath.
Revlew4 ready for oorteettom Phu Check Deposit, .
Trm col".
called Cantles Pekson Pian Cheek Wase
11t1e u Cala.
Pians picked up Construed"
-Flood plain plan
Plan roubral. ted ' - Mechanical
Grading pian
2'! Review, ready for correcdonome Electrical
Sabeoataetor Lbs
Called.contset Permn Plumbing
Grant Deed
-Pleas Ifted up g,M.L
H.O.A. Approval
Plans resabmUsed
Review* ready for tarreetioaw%m Developer Impact Fee
Phuelog App wal•
emi coataet Person
Pub. talcs. Apps
Date of permB bme
School Fee:
Total Permit Fen
,S & Pumping 3-52919
7$=680 Hwy 111, Ste. 123
Palm Desert;. CA 92260
CUSTOMER'S ORDER NO.
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