BSPN2017-001478-495 CALL_ FAX (760) 777-7011 E TAMPICO . V VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 5/8/2017
Application Number: BSPN2017-0014 Owner:
Property Address: 52860 AVENIDA VILLA ROQUE HEREDIA
APN: 773334007 44735 VIA ALONDRO
Application Description: HEREDIA /SAFETY METER RESET LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
Applicant: U Contractor:
ROQUE HEREDIA OWNER BUILDER
44735 VIA ALONDRO MAY 0 8 2011
LA QUINTA, CA 92253
CITY OF LA QUINTA
DESIGN AND DEVELOPMENT DEPARTMENT LIc. No.:
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
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�e,ts the applicant to a civil penalty of not more than five hundred dollars ($500).:
jf; 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
actors' State License Law.).
I am exempt under Sec. 4B.&P.Cthis reason
Date: �/ Owner:/
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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.).
Lender's Na
Lender's Address:
WORKER'S COMPENSATION DECLARATION '
hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a ceitificate,of consent to self -insure for workers'
:ompensation, as provided for by Section 3700 of the Labor Code, for the performance
if the work for which this permit is issued. .
_ I have and will maintain worbers' compensation insurance, as required by
iection 3700 of the Labor Code, for the performance of the work for which this permit is
ssued. My workers' compensation insurance carrier and policy number are:
tar r• Policy Number. _
I'certify that in the performaoce of the work for which this permit is issued, I
hall not employ any person in any marner so as to become subject to the workers'
:ompensation laws of California, and agree that, if I should become subject to the
Yorkers' compensation provisions of Section 3700 a Labor Code, I shall forthwith
:amply with t se pr visions.
)ate: �ApPlicsnt'.
NARNING: FAILURE TO SECURE WORKI RS' COMPENSATION COVERAGE IS UNLAWFUL,
%ND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
)NE HUNDRED THOUSAND DOLLARS (100,000). IN ADDITION TO THE COST OF
:OMPENSATION, DAMAGES AS PROVICED FOR IN SECTION 3706 OF THE LABOR CODE,
NTEREST, AND ATTORNEY'S FEES. "
APPLICANT ACKNOWLEDGEMENT
MPORTANT: Application is hereby made to the Building Official for a permit subject to
he conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose
equest and for whose benefit work is Performed under or pursuant to any permit issued
3s a result of this application, the owner, and the applicant, each agrees to, and shall
iefend, indemnify and hold harmless the City of La Quints, its officers, agents, and
?mployees for any act or omission related to the work being performed under or
ollowing issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not
:ommenced within 180 days from date of issuance of such permit, or cessation of work
or 180 days will subject permit to cancellation.
certify that I have read this application and state that the above information is correct.
agree to comply with all city and courty ordinances and state laws relating to building
:onstruction, and hereby authorize representatives of this city enter upon the above-
nenti]��Aignature
ty for inspection pumoses.
ate: (Applicant or Agent -
Bin it, �
City of La Qulnta
Building 81• Safety Division "
Pert 't #78-495 Calle Tampico
�j5 �Ai ori-O?7 101 �'i . La Quinta, CA 92253 - (760).777-701,2 {
Building Permit Application and Tracking Sheet
` Project -Address: VIZZ; Owner's Name:
A. P. Number: `'
-Address:, �.
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Legal Description:
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Address:Pr
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Tele h one:
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State Lic. # :
City Lic.
Arch., Engr., Designer:
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"Address:
City, ST, Zip:
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Name of Contact Person1
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Sq. Ft.:
#'Stories: # Units: ,
Telephone # of Contact Person�`7�
Estimated Value of Project: '=�✓v
APPLICANT: DO NOT WRITE BELOW THIS LINE ~
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Submittal -
Req'd
Rcc'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
/Amount
Structural Cafes.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calm.
Called Contact Person
Plan Check Balance.
Title 24 Cales.,"Plans
picked up
Construction '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
SubcontaetorList
Called Contact Person
Plumbing
Grant Deed
Plans picked up
II.O.A. Approval
Plans resubmitted
Grading
IN If OUSE:-
'"! Review, ready for correctionstissue
Developer Impact Fee
t
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr•
Date of permit issue
School Fees,
Total Permit Fees
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P.O. Box 1504 ,
LA QUINTA, CALIFORNIA 92247-15'04' BUILDING & SAFETY DEPARTMENT
78-495 CALLE TAMPICO
(760)777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
PROPERTY.OWNER'S PACKAGE
Disclosures & Forms for Owner -Builders Applying for Construction Permits
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IMPORTANT! NOTICE TO PROPERTY OWNER
e Dear Property Owner:
An application for .a buildin .pe" 't has been ubmitted in your name listing yourself as the builder of the property
improvements specified at
S
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.-
OWNER'S
uthority:OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF7NFORMATION '
° DIIR/ECTIONS: Read and initial each statement below to signer you understand or verify this information.
I understand a frequent practice of unlicensed persons is to have the roe owner, obtain an Owner -Builder'
'building permit that erroneousl lies that the roe property
YP property rty 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.
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.
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 in 1•as or her name instead of my
own.
217 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license nuin 1
permits and contracts. bers on
A�5.)I understand if I employ or otherwise engage any persons; other than California licensed Contractors, and the total va
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of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employers
under state and federal law.
`6. I understand if I am considered an "employer" under state and federal law, I must iegist✓r with the state and federal
government, withhold payroll taxes, provide workers' compensation disability insurance; and eontribute to unemployment
compensation for each "employee."'I also understand my failure to abide by these laws may su�
risk. ject me'to.serious financial
9//;-7 1 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 blicensed
`subcontractors and the number of.structures does not y exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
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 owners) that result from any latent construction defects in the
workmanship or materials.
. 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-
/8800 -3 1-CSLB (2752) or www.cslb.ca.gov.for more information about licensed contractors.
12 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
Plegal]�c�nd fjny illy res j ibl/e for proposed construction activity at the following address:
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Ie r L 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 Owner -Builders asmell 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 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 the�gency is required to be presented when the permit is issued to verify the property
owner's signature. �) „ ,
Signature of property Yowner
� ate:
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 ACTON 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):
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 owners signature.
Property Owner's Signature: Date:
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PERMIT NO. RS FA 017' DDl4
• SITE PLAN
NAME PHONED
SITE ADDRESS n
ASSESSORS PARCEL NUMBER
N Provide North Arrow REAR PROPERTY LINE
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