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11-0063 (ELEC)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: ll. -0000006 ' 3 Property Address: 79955 WESTARD HO DR APN: 649-071-006-16 -2190 Application description: ELECTRICAL Pronerty zoninsa; LOW DENSITY RESIDENTIAL Application valuation: 1000 ceitit 4 4v Q" Applicant: Architect or Engineer ----------------- LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 70001 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 a 'ant 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 Li nse Law.). 1 _ 1 I am exempt under Sec. , B.P. . for this reason—h Date: \ `\ p l �\ Owner:, CohSRLTION LENDING AG 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.I. Lender's Name: " Lender's Address: LQPERMIT Owner: JOHNSON GARY 79955 WESTWARD HO LA QUINTA, CA 92253 ( Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 1/18/11 A; CIT°/ r e r.,.. ., -LA ar7.a'3PJTA 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 AWORK e of the work for which this permit is issued, I shall not employ any person in any mato become workers' ompensation laws of California, and agree that, icome subj i to the work ' co p sation provisions of Section 1 (t 3700 of the Labhall ith ply with tho r isions. Date: 1d1 v\ 1` ;Applicant: WARNING: FAILURE TO SECURS' OMPENSATION AGE 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 t e a ve information i ect. I ree to comply with all city and county ordinances and state laws relating to but cons tion, d here b ut ize representatives of this ount to enter upon the above-mentioned property or ins ction oses. Date: Signature (Applicant or Agent): Application Number . . . . . 11-00000063 Permit .' . . . . . ELEC-SERVICE CHANGE . Additional desc . Permit Fee. 33.50 Plan Check Fee .00 Issue Date Valuation 0 Expiration Date 7/17/11 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 18.5000 EA ELEC SVC <=600V/<=200A 15.50 Special Notes and Comments ELECTRICAL SERVICE CHANGE 200 AMP., ------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited— Due Permit Fee Total 33.50 .00 .00 33.50 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 00 1.00 Grand Total 34.50 .00 .00 34.50 LQPERMIT .... Bin # ' ' = C►ty of La Quin to z r S Building 8£ Safety Division • a Permit # P.O. Box 1504, 78-495 Calle Tampico , ' La Quinta, CA 92253 - (760) 777-7012 f' •� ? _ Building.Permit Application and Tracking -Sheet ` ,r Proms jeet Address: �S�S �ec W�,,C� `:1 ti - .;Owner's Name: A. P. Number: Ado ress 9 9 S 5 Wes v v,:►Qc t't Legal Description: City, ST, Zip: L1 Oj Q l -j4+) • _ a Contractor: Q F •- I . 'Tel ehn Address: Project Description: City, ST, Zip Telephone: State Lic. # : City Lic. #; -Arch., Er'gr., Designer: Address: City., ST, Zip: ' Telephone:• � • - X. . •. Construction TY .. Type: Occupancy: P State Lic. #: Project twh� Pe (circle one):: New AddPn Alter Repair, r Dem o 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 Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. , Called Contact Person Plan Chemo Balance. 4 Title 24 Calcs. Plans picked up Construeion Flood plain plan Plans resubmitted Mechanical Grading plank i . 2°" Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing ' Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- ''" 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 P.O. Box 1504 LA QUINTA, CALIFORNIA .92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING !k SAFETY DEPARTMENT (760) 777-7012 FAX (760).777-7011 PROPERTY OWNER'S PACKAGE Disclosures & Forms for Owner -Builders Applying for Construction Permits ,IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner. An. application .for a building permit has been submitted in your name listing yourself as the builder of the .property improvements specifiedat We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible riskyou 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.ACKNOWLEDGMENT AND 'VERIFICATION OF INFORMATION _ DIRECTIONS: Read and initial each statement below to signify you understand or'derify this infermatdon. MI. .1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "O.wner-Builder" building permit that erroneously implies that the property owner is providing his or her own labcr and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries susaained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may rot provide coverage for those injuries. I am willfully acting as.an Owner -Builder and am aware of the limits of my insurance coverage forinjuries to workers on my property. I understand building permits are not required to be signed by property owners unlet ;s they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. understand as an "Owner -Builder" I am the responsible 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 _n his or her pame instead of my own. U64. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits 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. 6. f understand if I am considered an "employee' under state and federal taw, 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 mzy subject me to serious financial risk. 6;_5117- 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. 0� 8. 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 workmanship or materials. 9. I understand I 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- 800-321-CSLB (2752) or www.c-slb.ca.gov for more information about licensed contractors. G;A0. 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, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 2. I agree to notify the issuer of this form immediately of any additions; deletions, or changes 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 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 while working on your property; you may be held liable for damages. If you obtain a permit asOwner-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. Now A copy of the property owner's driver's license, form notarization, or other verification acceptable a agency is required to be presented when the permit is issued to verify the property owner's signature.50 1 Signature of property owne Date: g 1 l 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 understandis my personal responsibility, I hereby authorize the following person(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 presented when the permit is issued to verify the property owner's signature.. Property Owner's Signature: Date: