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BELC2017-0044R 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: ROQUE HEREDIA 44735 VIA ALONDRO LA QUINTA,'CA 92253 BELC2017-0044 52860 AVENIDA VILLA aw DESIGN & D0EENTDE�0A_,FTMEr%T-,_i .B PERI�M1-- (' MAY 0 9 2011 oDU)R R EDIA 773334007 .cn'OF4 AALONDRC HEREDIA RESIDENCE/ PANEL CHANGE o��E�DP S(GNAND D QUWTA LA QUINTA, CA 9225 $500.00 MENT DEPARTMENT 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: Contractor: OWNER / BUILDER Llc. No.: VOICE (760) 777-7125 FAX (760) 777-7011' INSPECTIONS (760) 777-7153 Date: 5/9/2017 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-ihsure 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: OWNER -BUILDER DECLARATION CarrA ZI Policy Number: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State r �I certify that in the performance of the work for which this permit is issued, I. License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any shall not employ any person in any manner so as to become subject to the workers' city or county that requires a permit to construct, alter, improve, demolish, or repair compensation laws of California, and agree that, if I should become subject to the any structure, prior to. its issuance, also requires the applicant for the permit to file a workers' compensation provisions of Section 3700 o e L bor Code, I shall f with 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 comply with th se pro isions. Date:_ V Applicant: 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 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, ($500).: AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO (_) I, as owner of the property, or my employees with wages as their sole ONE HUNDRED -THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF compensation, will do the work, and the structure is not intended or offered for sale. COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not INTEREST, AND ATTORNEY'S FEES. 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 APPLICANT ACKNOWLEDGEMENT are not intended or offered for sale. If, however, the building or improvement is sold IMPORTANT: Application is hereby made to the Building Official for a permit subject to within one year of completion, the owner; builder will have the burden of proving that the conditions and restrictions set forth on this application. he or she did not build or improve for the purpose of sale.). 1. Each person upon whose behalf this application is made, each person at whose (� I, as owner of the property, am exclusively contracting with licensed contractors request and for whose benefit work is performed under or pursuant to any permit to construct the project. (Sec. 7044, Business and Professions Code: The Contractors' issued as a result of this application , the owner, and the applicant, each agrees to, and State License Law does not apply to an owner of property who builds or improves shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and thereon, and who contracts for the projects with a contractors) licensed pursuant to employees for any act or omission related to the work being performed under or the Contractors' State License Law.). following issuance of this permit. �(a m exempt under Sec. . B.&P.C. f this reason 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 � Izlzwork for 180 days will subject permit to cancellation. Date Owner:- t I certify that I have read this application and state that the above information is correct. CONSTRUCTION LENDING AGENCY I agree to comply with all city and county ordinances and state laws relating to building I hereby affirm under penalty of perjury that there is a construction lending agency for construction, and hereby authorize representatives of this city t nr upon the the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). above-mentioAd pryperty for inspection purposes. , Lender's Name: ].Date. nt).%,<_Z 'Lender's Address: -1 DESCRIPTION ACCOUNT QTY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STAN DARDSADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT QTY AMOUNT SERVICES ,, 101-0000-42403 0 $25.33 DESCRIPTION ACCOUNT QTY °` AMOUNT SERVICES PC 101-0000-42600 0 $12.67 - Total Paid for ELECTRICAL: $38.00 DESCRIPTION ACCOUNT QTY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $96.27 Total Paid for PERMIT ISSUANCE: $96.27 DESCRIPTION ACCOUNT QTY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 -$5.00 _Bin # .• i Permit ;; Project Address: AV f � . �7 p � F•y {- .It� .Vt La QC.ii fta Building a Safety Division 78-495 Calle Tampico , La Quinta, CA 92253 - (760) 777-701,2 Building Permit Application and Tracking Sheet Owner's Name: / A. P. Number: Address: Legal Description: City, ST, Zip: Contractor: a / N TelP e hone: Address: - 7 ',-'3 t1 Project Description: City- ST, Zip: C/57,2 • � C�lox Tele � on ] P Q eE.. O Z � State Lic. # : City Lic. Arch., Gngr., Designer: Address: City, ST, Zip: TeIe h ne: Constructi n Type: State to Lic. #. 'Pa (circle one • New Add'n Alter Repair. Demo tY Name of Contact Person: Sq. Ft.: #Stories: # Units: Telephone # of Contact Person:- Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE tf Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Cates.. Called Contact Person Plan Check I•alance. Title 24 Calcs. Plans picked up Constructioni. ' Flood plain plan Plans resubmitted • Mechanical Grading plan 2"" Revicw, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. I-I.O.A. Approval flans resubmitted Grading IN If OUSE:- Jrd Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. APpr Dale'orpermit issue School Fees, ' . I Total Permio Fees I P.O: Box 1504 LA QUI-NTA;"CALIFORNIA 92247„-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & S+AFETY 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 buildin U pe t has b n ubrriitted in Your name listing yourself as the builder of the properly improvements specified at e l� We are providing you with an Owner -Builder Acknowledgment and Information Verification Form— 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. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS.- Read and initial each statement below to signs you understand or verify this information. 1. I understand a fiequent 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. 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 �% on my property. 4 2. 1 understand building permits are not .required to be signed b roe owners unless construction and are riot hiring a licensed Contractor to assume this,responsiblity. they are responsible for the 3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 12h 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their 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 be considered an "employer" under state and federal law. )PZ/6. 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 risk. )ellel-7. I understand under California Contractors' State License Law, an e Owner -Builder who builds sin 1 - g 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. i o8. 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 a9 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- 800-32 1-CSLB (2752) or www.cslb.ca.gov.for more information about licensed contractors. 11211-11,. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the pa legal nd fi nci lly res onsr 1 for proposed construction activity at the following address: I 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 Owrier-Builders as.well as employers. 12. 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 Contractois 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 the�rgency is required to be presented when the permit is issued to verify the property owner's signature. 7 Signature of property owner _Gt�G� � Date: -51a,,k� 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 agents) to apply for, sign, and file the documents necessary to obtain an Owner-Buildei 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 bepresented when the permit is issued to verify the property owners signature. Property Owner's Signature: Date: