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09-0004 (RR)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Applicant: 4 VOICE (760) 777-7012 FAX (760) 777-7011 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 1/05/09 Owner: - NETZLEY GERALD R 52273 AVENIDA VILLA LA QUINTA, CA 92253 --------------------------------- Contractor: a Architect or Engineer: Owner D (nl o 5 �Q�9 CITY OF LA QUIN -'A ----------------- 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 Professionals 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 permlt 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).: ( 1 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 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 anowner of property who builds or improves thereon, and who contracts for the���PPProjects with a contractorlsl licensed pursuant to the Contractors' Stat,LIens.1. n 1 ) I am exempt under Sec. B & .C. r this reason ate: t — S" 05 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.I. Lender's Name: ul - Lender's Address: LQPERMIT 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 -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 insurance carrier and policy number are: - Carrier Policy Number I certlfy.that, in the performance of the work for which this permit is issued, I shall nut empluy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if Ishoul b ome subject to th rs' compensation provisions of Section / 3700 of the Labor C , 1 a ort it th those provisions. Ds-,01A ant: /WARNING: FAIL RERE TE WORKERS' COMPENSATION ERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANDCIVIL FIE 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 Director of Building and Safety 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 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,issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is corre I ee o comply with all city and county ordinances and state laws relating�Io build' /conructio , and her a or' -representatives of thi;.county to enter upon the above-mentioned p recC purp e D/ate: /.—r`a9 S'ture (Applicant or Agen Application Number: 097,00000004 Property Address: 52273 AVENIDA VILLA APN: 773-273-012-2 -000000- Application description: RE -ROOF Property Zoning: COVE RESIDENTIAL Application Valuation: 36UU Applicant: 4 VOICE (760) 777-7012 FAX (760) 777-7011 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 1/05/09 Owner: - NETZLEY GERALD R 52273 AVENIDA VILLA LA QUINTA, CA 92253 --------------------------------- Contractor: a Architect or Engineer: Owner D (nl o 5 �Q�9 CITY OF LA QUIN -'A ----------------- 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 Professionals 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 permlt 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).: ( 1 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 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 anowner of property who builds or improves thereon, and who contracts for the���PPProjects with a contractorlsl licensed pursuant to the Contractors' Stat,LIens.1. n 1 ) I am exempt under Sec. B & .C. r this reason ate: t — S" 05 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.I. Lender's Name: ul - Lender's Address: LQPERMIT 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 -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 insurance carrier and policy number are: - Carrier Policy Number I certlfy.that, in the performance of the work for which this permit is issued, I shall nut empluy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if Ishoul b ome subject to th rs' compensation provisions of Section / 3700 of the Labor C , 1 a ort it th those provisions. Ds-,01A ant: /WARNING: FAIL RERE TE WORKERS' COMPENSATION ERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANDCIVIL FIE 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 Director of Building and Safety 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 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,issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is corre I ee o comply with all city and county ordinances and state laws relating�Io build' /conructio , and her a or' -representatives of thi;.county to enter upon the above-mentioned p recC purp e D/ate: /.—r`a9 S'ture (Applicant or Agen Application Number 09-00000004 1 Permit RE -ROOF' Additional desc Permit Fee 30.00- Plan Check Fee 00. Issue.Date Valuation 0 . Expiration Date.. 7/04/09 Qty Unit Charge Per Extension BASE FEE 30.00 Cpcoial Notoo and _Commonto --------------------------- REMOVE & REPLACE ROOF WITH NEW SHINGLES -------------------------------------------- Other Fees . . . . . ------------------ BLDG STDS"ADMIN (SB1473)' 1.00 Fee summary Charged Paid Credited Due Permit.Fee Total - 30.00 ----------------- --- ---------- .00 .00 30.00 Plan Check Total .00 .00 .00 00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 31.00 00 .00 31.00 LQPERMTT - - P.O. BOX 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY -OWNER'S PACKAGE (760) 777-7012 FAX (760) 777-70.11 Disclosures & Forms for Owner -Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An. application for a building permit has been submitted in your name listing yourself as -the builder of the property improvements specified. at 5- 2 2 3 At, e. U 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 unde-standing 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 signify 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" ding permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as <. 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 overage for injuries to workers In my property, 2. I 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. �/ . I understand as, an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect self from potential financial .risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own fnderstand Contractors are required by law to be licensed and bonded in California. anc to list their license numbers on d contracts. nderstand 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" r state and federal law. 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal vernment, withhold payroll taxes, provide workers' compensation disability insurance, a: --id contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial )?bc/onti ' understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential ures cannot .legally build them with the .intent to offer them for sale, unless all -Mork is performed by licensed actors 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. Vncnderstand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any r personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the ror anship or materials. 9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue ervice, 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. Vartylegally am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the 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, I will abide by all plicable 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 ave 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 oremployee 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 dri'ver's license, form notarization; or other verification acceptable to the agency is required to be resented when the permit is issued to verify the property owner's signature. ' L Signature of property owner Date: t — d 5 - 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 understandis 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. tt `` n Scope of Construction Project (or Description of Work): AQ_ m n d (� a 1 /t -� ; w c / Q goof K� f� t T°1 t d `J Project Location or Address: 2 — Z 7 3 A v i o, Name of Authorized R Agent: e. Q'i �% � � 2 S `1 Z 7 r g � `1� cw��ClTel No i 6 0 3 Address of Authorized Agent: j, a t 1 t 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 w the,permit is issued to verify the property owner's signature. Property Owner's Signature:' Date: / — S 0 Bin # City of La Quinta Building 81 Safety Division Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit #P.O. p�( a,, Project Address: --Z -7 114 Owner's Name: LAA-10�+ �e A. P. Number: Address: S- Z - 2 7 3 e Legal Description: 3 (d A R.lq Contractor: City, ST, Zip: �,y ~ ,�A (A )J � 275 - Telephone: ?� o- S e y3Z75- Address: Address: Description: Project � p Qvc a In S ;w ier City, ST, Zip: 6 F F �oo� R N;z w Telephone: p S o0 7 wd �w S�Gi1 C w )CS State Lic. # City Lic. #: Arch., Engr., Designer: Address: City, ST, Zip: Telephone: w� State Lic. #: Name of Contact Person: Construction Type: Occupancy: Project type (circle one): New Ad -9'n Alter Repair Demo Sq. Ft.: # Stories: # Units: Telephone # of Contact Person: 0c Estimated Value of Project: ( 4 APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Rec'd TRACKING PERMfT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Che --k Deposit Truss Calcs. Called Contact Person Plan Che --k Balance Energy Cales. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2°" Review, ready for correctionsfissue Electrics; Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- M 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 Pe-mit Fees