BWFE2017-009578-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
,1411
DESIGN & D
Application Number: BWFE2017-0095 .
Property Address: 51401 AVENIDA VIILLA
APN: 773102006
Application Description: MOLLER RESIDENCE / BLOCK WALL
Property Zoning:
Application Valuation: $10,000.00
Applicant:
LISA MOLLER & WALTER URBAN
2609 N SEPULVEDA BLVD
MANHATTAN BEACH, CA 90266
D wa�r��y VOICE (760) 777-7125
FAX (760) 777-7011
.O E ) DEPARTME INSPECTIONS (760) 777-7153
BUILDI � ERMIT,AY 3 Q
�IVV�� 2011 1 U)
wner:L')
CII-YDE(A QU%1 HOLLER & WALTER URBAN
DESIGN AND DEVELOPMENT DA BLVD
MANHA EACH, CA 90266
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 {commencing with Section 70001 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. for this reason
3o 17 --
Dates Owner:
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 Name:'
Lender's
Contractor:
OWNER / BUILDER
Llc. No.:
Date: 5/30/2017
WORKER'S COMPENSAMON DECLARATION
I hereby affirm under penalty of perjury one o 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 insuran(2 carrier and polity 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 Section T/00 of the Labor Code, I shall forthwith
comply with �Vg
Date:- _-.Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMIPAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,00). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOF: 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 appli:ation 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 ssuance of such permit, or cessation of
work for 180 days will subject permit to cancel ation.
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 ordiaances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above- ent�property for inspection purposes.
Dater 1/(J Signature (Applicant orAge
Date: 5/30/2017
Application Number: BWFE2017-0095
Owner:
Property Address: 51401 AVENIDA VIILLA
LISA MOLLER & WALTER URBAN
APN: 773102006
2609 N SEPULVEDA BLVD
Application Description: MOLLER RESIDENCE / BLOCK WALL
MANHATTAN BEnCH, CA 90266
Property Zoning:
Application Valuation: $10,000.00
Applicant:
Contractor:
LISA MOLLER & WALTER URBAN
OWNER / BUILDER
2609 N SEPULVEDA BLVD
MANHATTAN BEACH, CA 90266
---------------------------------------------------------------------------------------------
Llc. No.:
Detail: 160 LF X 6 FT HIGH BLOCK WALL [ANGELUS SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL.BE COVERED W9TH STUCCO, PAINT, OR TEXTURED
COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF CURB AND ANY FENCING SHALL BE LANDSCAPED, HAVE A
SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016 CALIFORNIA BUILDING CODES.
FINANCIAL INFORMATION
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WALL/FENCE - EA ADDITIONAL 50 LF
101-0000-42404
0
$30.40
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 100 LF
101-0000-42404
0
$50.67
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 100 LF PC
101-0000-42600
0
$63.33
Total Paid for BLOCK WALL: $144.40
DESCRIPTION
ACCOUNT
1QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306
0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
TOTALS:
P.O.Tdf 4 4 Quha
BOX 1504,
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760)77777012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building e your name yourself as t
t has been submitted in listing of the property
improvements specified at Id 6�Ut✓'Io1l 0�,( ( Q ti I N C�.
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.
Read and initial each statement below to signs you understand or verify this information.
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
ilding 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.
I understand building permits are not required to be signed by property owners unless they are responsible for the
7Konsction and are not hiring a licensed Contractor to assume this responsibility.
I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
ow/4.
I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits a contracts.
5. I understand if I employ or otherwise 'engage.any persons, other than California licensed Contractors, and the total value
my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
Vvernment,
e and federal law.
understand if I am considered an "employer" under state and federal law, I must register witl- the state and federal
withhold payroll taxes, provide workers' compensation disability insurance, and contrib-ite to unemployment
compensation for each ".employee." I also understand my failure to abide by these la
risk. ws may subject ire to.serious financial
7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
ctures 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 tLe work is performed
under contract with a licensed general building Contractor.
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.
Klervi9ce,the
understand I may obtain more information regarding my obligations as an."employer" from the Internal Revenue
United States Small -Business Administration, the California Department of Benefit Payments, and the California
V800-321-
dustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
B (2752) or www.cslb.ca.gov for more information about licensed contractors.
aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
: and financiall responsible for pro osed construction activity at the following address:
51µb1 t1 u,A I LA V h itv�
1. I a ee that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
ap!!2iclable aws and requirements that govem Owner -Builders as mell 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
ve 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 agency is required to be presented when the permit is issued to verify the property
owner's signature. �
Signature of property owner Date: �2/
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):
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 propertyowners signature.
Property Owner's Signature: Date:
Bin #
Qty of LQ Quin
Building &r Safety Division
78-495 Calle Tampico
(,�,Pr La Quinta, CA 92253. - (760) 777-7012
y a) �uilding Permit Application and Tracking Sheet
Permit #
Project Address: J C. ��
Owner's Name: tAcA MOUEP_ l W A M;P, UF4�?
A. P. Number: 3 '' n /1.-- D D lt/ —
Address:7-b0q N ,C,-,e�-FL)W 6M (51_V(-)
Legal Description:
Contractor:
City, ST, Zip: RANI+,r�-rTA fdEA6HGA Oto
Telephone: hone: '7100 g -375
l�
Address:
Project Description:
City, ST, Zip:
Telephone:
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1!J
State Lic. # :
City Lie. #;
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Construction Type: C an cY•.
'�P
-Project type one): NAdd'a Alter Repair Demo
Name of Contact Person:
Sq. FL:
#Stories:
#Units:
Telephone # of Contact Person:
r
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 Check Balance
Title 24 Cales.
Plans picked up
Constructicn
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
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 Perrot Fees
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SAFETY DEPT.
AAPPROVED
OVER
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