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09-0957 (BLCK).a - , P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 T4&t 4 4 Q". BUILDING & SAFETY DEPARTMENT BUILDING PERMIT VOICE (760) 777-7012 FAX (760) 777-7011 'VAIs (760) 777-7153 �'y!04 '4 Application Number: C 09:-00000951 Owner: �Op��o 'qO Property Address: 6445 WASHINGTON ST , FERNANDO NELSON APN:643-182-020-1 -2043 - 46445 WASHINGTON STREET �� Application description: WALL/FENCE LA QUINTA, CA 92253 --------------------------------- .Property Zoning: LOW DENSITY RESIDENTIAL � � O , Application valuation: 2025 Contractor. Applicant: Architect or Engineer: ',Owner _ --------------,----------------- LICENSED CONTRACTOR'S DECLARATION - - WORKER'S COMPENSATION DECLARATION ' I hereby affirm under penalty of perjury that 1 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. - - _ 1 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 Labor _ 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: hereby affirm under penalty of perjury that I 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 performanceof the work for which this permit is issued, I 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, r 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 should become subject to the workers' compensation provisions of Section License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the for e, s II forthu*thpl;: I ththat 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).: Date: pplicant: W) 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 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL ^• Contractors' State License Law does not apply town owner of property who builds or improves thereon, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO 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 PROVIDED FOR IN improvements are not intended or offered for sale. If, however, the building 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.). APPLICANT ACKNOWLEDGEMENT (_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application. ` property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed .1. Each person upon whose behalf this application is'made, each person at whose request and for pursuant to the Contractors' State License Law.). whose benefit work is performed under or pursuant to any permit issued as a result of this application, (_ 1 I am exempt under Sec. , B.&P.C. for this reason the owner, and the applicant, each agrees to, and shall defend, indemnity 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. ate: ^ ` wner: _ 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 CONSTRUCTION LENDING AGENCY permit to cancellation. I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify that I have read this application a d state that the above information is correct. 1 agree to comply with all work for which this permit is issued (Sec. 3097, Civ. C.). - city and co my ordinances and state I s relating to buil ' construction, and hereby authorize sentatives of this my to enter upon the ab mentioned pro rty for . spection poses. Lender's Name: // °���G/j - ];X,. Signatu Applicant or Agent " Lender's Address: Vk 4 LQPERINIT Application Number . . . . . 09-00000957 Permit . . . WALL/FENCE PERMIT Additional desc . Permit Fee . . . . 54.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 2025 Expiration Date'. 3/03/10 Qty Unit Charge Per Extension BASE FEE 45.00 1.00 9.0000 THOU BLDG 2,001-25,000 9.00 ----------------- Special Notes and Comments -- 81 L.F. 6- GARDEN WALL, CITY STANDARD @ SIDE PROPERTY LINE. 2007 CODES -----------------_---------------------------------------------------------- Other Fees . . . . BLDG STDS ADMIN (SB1473). 1.00 Fee summary Charged Paid Credited Due Permit Fee Total 54.00 .00 .00 54.00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 00: 1.00 Grand Total 55.00 .00. .00 55.00 LQPEINIIT P.O. B.ox 1504 LA QUINTA, CALIFORNIA 92247,1504 78-495 CACLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT (7'60) 777-70.12 PROPERTY OVA S PACKAGE FAX (760) 777-7011 Disclosures & Forms: for Owner -Builders Applying for Construction Permits LMPOTANT! NOTICE TO PROPERTY OWNER Dear Property Owner. An. application .for a build't has been. ubmitte4 in your n e' lis g yourself as the builder of the _property improvements specified at r� �- ! _ We are.providing you with an Owner -Builder Acknowled .nt and.Inf ation -Verification Form to make you aware of your responsibilities and possible.risk you 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. ONMER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each. statement below to'signify you un'd'erstand orvenfy this information. 0&/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 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. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. 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 responsibility.. 3. I understand as an "Owner -Builder" Lam the responsible.party of record on the permit. I understand that I may protect yself 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 by law to be licensed and bonded in California and to list their license numbers on ermits and contracts. - y 5.1 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" jdeur state and federal law_6. 1 understand ifI am considered an "employer" under state and federal law, I must register with the state and federal rnment, 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. s 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential s cturecannot .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. 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 ikormanshipormaterials.9.Iunderstand Imay obtain more information regarding my obligations as an "employer' from the Internal Revenue ce, 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.cslb.ca.gov for more information about licensed contractors. 10_ 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: 1. I agree that, as the party legally and financially responsible for this proposed construction activity,.) will abide by all able 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 We 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'eivil 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 as Owner -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. Note: A copy of the property owner's ariver'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_ / Signature of property owner_ Date: 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 1 understand. is my personal responsibility, I hereby authorize the following person(s) to act asmy 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:�lQ 7 CI t �(1Z, Ai. rw 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 pre .ented when thermit is issued to verify the property owner's signature_ Property Owner's Signature: Date: City of La Quinta Building 8t Safety Division Permit # P.O. Box 1504,18-495 Calle Tampico .0t La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet ►r <Piije&-Address: (( Ow�--w"' \ s . ner's Name: A. P. Number: b 04 Address `q (p q q�r Legal Description: "'" =' City, ST, Zip: �-6 G 5� Address: Pro f Description: t City, ST, Zip: Telephone: State Lic. # : City Lic. #; Arch., Engr., Designer: Address: City., ST, Zip: Telephone: w< ,,:• v. '•~ ; ' Construction Type: Occupancy: State Lic. #: f.^,. ;^ :• .wok":: c,'r=. Project type (circle one): New Add'n Alter Repair Demo Name of Contact Person: Sq. FL: # Stories: #Units: Telephone # of Contact Person:Estimated-Value' fo eject: APPLICANT: DO NOT WRITE. BELOW THIS LINE # Submittal Req'd Recd TRACMG PERMIT FEES Plan Sets- Plan Check submitted Item Amount Structural Cafes. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Tithe 24 Cafes. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2" Review, ready for correctionvissue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up. S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:-: '^' Reyiew,.ready for correctionstissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees