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11-1107 (RER)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 c&t!t 4 4 Q" Application Number: 11-00001►1T07 Property Address: -78222 CALLE FORTUNA APN: 770-154-006-6 -000000- Application description: REMODEL - RESIDENTIAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 200 Applicant: Architect or Engineer: ------------------ LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 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).: 1._ I 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 Cade: 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.). (_ 1 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.l. ( 1 I am exempt under Sec. , B.&P.C. for this reason work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: Lender's Address: LQPERMIT Owner: FREDERICKS JEFF/DENINE 78222 CALLE FORTUNA LA QUINTA, CA 92253 Contractor: Owner LiC. No.: ---------- VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 10/07/11 --------r_y---- -- WORKER'S COMPENSATION DECLARATION 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 201 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 th rkers' compensation provisions of Section 3700 of the Labor Code, I shall forttVvith copfpVwith those provisions. WARNING: FAILURE TO SECURt-WFSRRE COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES.ANO 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 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 correc I agree to comply with all' city and county ordinances and state laws relating to build' g construction, and her y authorize representatives of this county to enter upon the above-mentioned prop�or i94-ction,wfpos LQPERMIT Application Number .11-00001107 Permit BUILDING PERMIT Additional desc . Permit Fee . . . . 15.00 Plan Check Fee 9.75 Issue Date Valuation 200 - Expiration Date 4/04/12 Qty Unit Charge .Per Extension BASE FEE 15.00 --------------------------------------- ------------------------------------ Special Notes and Comments ADDING INTERIOR WALLS TO INSIDE OF GARAGE NON-STRUCTURAL 2010 CODES -----------------------------•----------------------------------------------- Other Fees . ... . . . . BLDG STDS ADMIN (SB1473) 1.00 ENERGY REVIEW FEE .98 Fee summary Charged Paid Credited Due --------------------------- Permit Fee Total ------------------------------ 15.00 .00 .00 15.00 Plan Check Total 9.75 .00 .00 9.75 Other Fee Total 1.98 .00 .00 1.98 Grand Total, 26.73 .00 .00 26.73 he CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED�- FOR CONSTRUCTION D TE.O - // BY s5Z o 6N ,-O.VX 701. fe u9 o /Z ' I I 9,'g ue21 7i 't i .71 �a, a, fD OL pji� CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVE® FOR CONSTRUCTION DATE Q _ - �( — BY `- '- P2 toP, To Fi riA L Smoj�E MgNlYdJ& L�TEG>0� 7a (� i�✓57,� a� a z 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) 777-7011 Disclosures & Forms for Owner -R.0 lders Applying for Construction Permits am-aRTANTt NOTICE TQ I?RQPERTV OM- 1 --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 We are providing you with an Owner -Builder Acknowledgment and Information Verification Foran 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 offieial address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OV4 'S ACKNOWLEDGMENT AND VERNWATION OF RWORMATION DIREMONS. Read and initial each statement below to stgn#y you understand or verify this information. L I understand a fiNuent 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. 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. ounderstand building permits are not required to be signed by property owners unless they are responsible for the nst�,tiOn and are not hiring a licensed Contractor to assume this responsibility.. 3. I understand as an "Owner -Builder" I am the responsible party of record on the permiL I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the.permit filed in his or her name instead of my own. . I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. mS. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value y construction is at.leasi five hundred dollars ($500), including labor.and materials, I may be considered an "employer under state and federal law. I understand if I am considered an "employer" under state and federal law, I must register with the state and feder overnment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployme compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious fnanci risk. AeI understand under California Contractors' State License Law, an Owner -Builder who builds single-family resident ctures cannot .legally build them with the intent to offer them for sale, unless all work is performed by licem subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perforn 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 igjuries sustained. by any subsequent. owner(s) that result from any latent construction defects in the workmanship or materials. . . 60?9_ I understand I may obtain more• information regarding my obligations as an "employee' from the Internal Revenue emce, 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. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the "Irk' legally and financially responsible for proposed construction activity at the following address: e11. 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. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any Of the 140fmation 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 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 We Contractors, You will be fEsponsfble for ver&fw whether or not those Contractors are pco_p_e_dy tic—eased tic-easedand 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.perndt. Now A copy of the property owner's daiver'sLia, form notat+tzatioN or other verification acceptable to the agency is requbed to be presented when the permit is issued to rerefy the property owner's signature. Signature of property owner Date: la— 7—a-42 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 personalty filled out the abo 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 owner's signature. Property Owner's Signature: Date: Bin # Qty Of La Qulhta BAHO.- ff Safety MM6n Pennit # P.O. Box 1504,*78-495 Calle TaMPICO Lj.Quinta, CA 92253 -:(760) 777-7012 Building Permit Application and Tracking Sheet Project Address: 1-7 Owner's CA-),4Own's Name:. (j eA jy A- P. Number. "770 IT oo(. Address: 76 A22 00J ro 7�19_ s, A Legal Description: City, ST, Zip: 'A _33 Contractor. Address: Telephone: Project Description: City, ST, Zip: Telephone. State Lie. #City Lic. 9, Arch, Engr., Dtysigner. Address: City, ST, Zip: Telephone: State Lie. #: Name of Contact Persom.—T#—TJniw Construction Type:, Lv oao Occupancy: Project type (circle one):. Now Add'n Alt Repair Demo Sq. Ft: Stories: Telephone # of Contact Person: N Submittal Reqld Plan Sets Estimated Value of Project: -APPLICANT: DO NOT WRITE BELOW THIS LINE Recd TRACING PERMIT FEES Plan Check submitted Amonat' Structural Calm Reviewed, ready for corrections PlanChc&Deposit. Truss Calm Caged Contact Person Plan Check Balance, Tide 24 Calci. Plans picked up Construction Flood plain plan Plans resubmitted Mech'afilcal Grading plan 2`' Rtvtew, ready for correctiousAssue Electrical Subcoutactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.L H.O.A. Approval Plans resubmitted Grading IN HOUSE;- Review; ready for correctionsAssuc Developer Impact Fee PlanalagApproyal. Called Contact Person A.U.P. Pub. Wks. Appr Date of permit issue toll School Fees Total Permit Fm