BSPN2017-002178-495 CALLE TAMPICO Twit 4.4 0":
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
' Date: 6/21/2017
Application Number: BSPN2017-0021 Owner:
Property Address: S2805 AVENIDA VILLA U RACHEL RUBUE
APN: 773333016 52805 AVENI 3A VILLA
Application Description: RUBUE RESIDENCE / UTILITY R ASE. JUN 2 1 2017 LA QUINTA, CA 92253
Property Zoning:
Application Valuation: $100.00
CITY
Qf
• DESIGN AND DEVELOPMENT QUINTA
Applicant: NT DEPARTMENT Contractor:
RACHELRUBUE
52805 AVENIDA VILLA
LA QUINTA, CA 92253
Llc. No.:
r
------------------------------------------------=---------------------------------------------
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 Professions 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 any 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
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 License Law.).
(_) I am exempt under Sec. B.&P.C. or t is reason
Date: 1 i6wner:
CONSTRUCTION LENDING AGENCY
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.).
Lendef's Na
Lender's Address:
WORKER'S COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certEicate 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 issuec..
I have and will maintain worke.;s' 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 I should become subject to the
workers' compensation provisions of Sect -on 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date:
Applicant:
WARNING: FAILURE TO SECURE WORKEP5' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CF.IMINAL 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 Building Official 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 peoformed under or pursuant to any permit
issued as a result of this application , the .)wner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmleso the City of La Quinta, its officers, agents, and .
employees for any act or omission relatec to the work being performed under or
following issuance of this permit.
2. Any permit issued as a result of this z pplication becomes null and void if work is
not commenced within 180 days from da:e of issuance of such permit, or cessation of
work for 180 days will subject permit to oncellation.
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
construction, and hereby authorize representatives of this "upcityabove-mention d property for inspection purposes.
Daterf' Signature (Applcant or Agent);M1
Date: 6/21/2017.
Application Number:
BSPN2017-0021
Owner:
Property Address:
52805 AVENIDA VILLA
RACHEL RUBUE
APN:
773333016
52805 AVEN@JA VILLA
Application Description:
RUBUE RESIDENCE / UTILITY RELEASE
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
$100:00
Applicant:
Contractor:
RACHELRUBUE
52805 AVENIDA VILLA '
LA QUINTA, CA 92253,
Llc. No.:
Detail:. .
SPECIAL INSPECTION 101-0000-42404 0
$76.00
` Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION:
$76.00
DESCRIPTION
ACCOUNT
CITY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$S.00
m
Bin #
Ci(( of La Qu«nta .
Building & Safety Division
Permit ,f 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-701,2
Building Permit Application and racking S:)eet
Project Address: (�,{,oN I Owner's Name:
A. P. Number:
Address:a OS
Legal Description:
City, ST, Zip:
ntr r
Co act '
0
ele hone:
TP c. -70
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Add ress:4
Proj t escription:W? CZ41
City, ST, Zip:
Te •
le h nc
P o .
State Lic. # :
City Lie. #:
Arch., Gngr., Designer:
Address:
City, ST, Zip:
Telephone. e:
Constructionn Type: O eau P ancY•
,.
State /<
S to Lic
roJ ctPnPa (circle one • New Add'n Alter Repair Demo.
Name of Contact Person:
S
# S ries:
#Units:
Telephone # of Contact Person:
Estimated Value of Project-'�v•,
APPLICANT: DO NOT ITE BELOW THISEH2
tl Submittal Rcq'd Rec'd TRACKING PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for corrections
Plan Check Deposit '
Truss Cates.
Called Contact Person
Plan Check Balance.
Title 24 Cates.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"d Review, ready for corrcctions/issue
Electrical .
Subcontactor List
Called Contact Person
Plumbing
1
Grant Deed
Plans picked up
S.M.I.
r
H.O.A. Approval.,
Plans resubmitted
Grading
IN HOUSE:-
"Rcvieiv, ready for corrcctions/issuc
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit. issue
School Fees,
Total Permit Cees
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P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUiN.TA, CALIFORNIA 92253
.�QuG�1a
BUILDING & 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 peiTriit has been submitted in your name listing yourself as the builder of the property
improvements specified at
We are providing you with an Owner -Builder. Acknowledgment and Information 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:
..•..........�.L �i.>nar>«[i11v1�.VI' lIVrVKlV1A17UN "
DIRECTIONS: Read •and initial each statement below to signs you understand or verify this infor-nation. .
I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
tuilLg permit that erroneously implies that the property, owner is providing his or her own labor wand material personally. 1, as
an Owner -Builder, may beheld 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. I understand building permits are not required to be signed by property owners unless he responsible
construction and are not hiring a licensed Contractor to assume this responsibility. Y are P for the
3 I understand,as an "Owner -Builder" 1 am the responsible party of record on the permit I understand that I may protect
rrhyseli
from Y
m 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 thea license numbers on
permits and contracts.
5. 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 b•:.considered an "employer"
under state and federal law.
6. 1 understand if 1 am considered an. "employer" under state and federal law, I must regisiE'r with the state and federal
overnment, withhold payroll taxes,rovide workers' compensation mpensahon disability insurance; and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may suLj*ect me to.serious financial
risk.:
7. I understand under California Contractors' State License Law, an Owner -Builder who bui'ids single-family residential
srn ices 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 a'1 of the work is performed
under contract with a licensed general building Contractor.
P
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.csib.ca.gov for more information about licensed contractors.
10. 1 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.
1 . I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
have rovided 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 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 driver's license, form notarization, or
other verification acceptable to tlr a ncy is required a presented when the permit is issued to verify the property
owner's signature.
Signature of property owner Date: off/
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 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 necessary to obtain an Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work): / �r
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent: SA
Tel No
I declare under penalty of perjury that I am the property ow�t for the address listed above and I personally fulled out the above
information and certify its accurac ote. A copy of the owne 's driver's license, form notarization, or.other ver f cation
acceptable to the agency is requ' d to b presente en t permit is issued to verify the prroperty caner s signature.
Property Owner's Signature: / Date: �` ���