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12-0530 (BLCK)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number:-- 32-00000530—=_,___ Property Address: (54595 -AVENIDA HERRERA APN: 774-282-016-5 -000000- Application description: WALL/FENCE Property Zoning: COVE RESIDENTIAL Application valuation: 1250 Tjht �� VOICE (760) 777-7012 FAX (760) 777-7011 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 5/11/12 Owner: ALLA TITENSKY 54595 AVENIDA HERRERA LA QUINTA, CA 92253 --------------------------------- Applicant: Architect or Engineer: 0 V�l �� 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 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 ay pplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•: () 1, 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 o er own employees, provided that the improvements are not intended or offered for sale. If, o ever, the building or improvement is sold within one year of completion, the owner -builder will havfon rden of proving that he or she did not build or improve for the purpose of sale.). (_) I, as owner of the property, am exclusively contractingcensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contratate License Law does not apply to an owner of property who builds or improves thereon, and whocts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). 1 _ 1 I am a mpt nder Sec. , B.&P.C. fo i e /te: 1614, ,e-w—ner: CONqconst ronrl.nding NG AGENCY I hereby affirm u der penalty of perjury that there is agency for the performance of the work for which this permit is issued (Sec. 3097, Civ Lender's Name: ��►--} /—j,— Lender's Address: LQPERMIT Contractor: Owner _ MAY 1 2 2012 CITY OF LA QUINTA FINANCE DEPT. 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 insurances required by Section 3700 of the Labor Code, for the performance of the work for /,the �rmit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy Num itI certify that, in the performance of the work fs permit is issued, I shall not employ any person in any manner so as to become subjorkers' compensation laws of California, and agree that, if I should become subject trs' compensation provisions of Section _/00 of the Labor Code, I shall forthwith cthose provisions. WARIyING: FAILURE TO SECURE WORKERJ' COMP ION COVERAGE IS UNLAWFUL, AND SHALL JECT NAL LT I ES UP TO ONE HUNDRED THOUSAND DOLLARS $100,0 0)•E NTADDIIT ADDITION TO T COE COIMPENSAT ON, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTE ST, 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,Jact ll defend, indem ify and hold harmless the City of La Quinta, its officers, agents and employeny act or omi 1 related to the work being performed under or following issuance of this2. Any permit issued as a result of this applicaties null a id if work is not commenced within 180 days from date of issuance of suit, or ce a 'on of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that thenform n is correct. I agree to comply with all city and county dinances and state laws relating to buildtruc , and hereby authorize representatives of�this c y t en er upon the above-mentioned propertpec n purposes. 8"ate: / ure (Applicant or Agent): Application Number . . . . . 12-00000530 Permit . . . WALL/FENCE PERMIT Additional desc . . Permit Fee . . . . 31.00 Plan Check Fee 00 Issue Date . . . . Valuation . . . . 1250 Expiration Date . . 11/07/12 Qty Unit Charge Per Extension BASE FEE 15.00 8.00 2.0000 HND BLDG 501-2,000 16.00 ---------------------------------------------------------------------------- Special Notes and Comments 50 L.F. 6' GARDEN WALL @ REAR P/L LINE, CITY STANDARD. 2010 CODES. ---------------------------------------------------------------------------- Other Fees . . . .. . . . BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged Paid Credited ---------------------------------------- Due ----------------- Permit Fee Total 31.00 .00 .00 31.00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 32.00 .00 .00 32.00 LQPERMIT ICITY OF IA QUINTA BUILDING & SAFETY DEPT. APPROVED OR CONSTRUCTION DATE gy-ifjl_ P.O. Box 1504 LA QUINTA; CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OVM' EW S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms, for Owner -Builders Applying for Construction Permits 4WM,TA. Y KOT>ECE W ER(Wiki TY OWNER Dear Property Owner :. application for a bulla permit has been submitted irr y ur name listing yourself as the builder of the property impMvements specified at JV-54?5 aV :V� i We are providing you with an Owner -Builder Acknowledgment and In€ot nation Verification Form to make you awaaa0 your Fespoaslbilities and possible risk you may incur by having this permit•imted. in your name as .the Owner -,Builder. We will not Issue a building -permit until you. 4ave 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 thismotice unless you, the property owner, obtain the prior approval.of the permitting authority. ONMRS AeKNOWI:LD�T AM YERMCAM8N M UW0 V AIWN Dfi%E 7OONS. Read and "'itiat each: statin mt bt&W tb signify you widwstand or veno this Mformadon. k1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an -Owner-Builder" building pernut that erroneously implies that the property owner is providing his or her own labor and material personal%i. 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 - 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. 3. I understand as. an "Owner -Builder" I am the responsible.party of record on the permit. I understand that I may protect my If from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her natrie instead of my o/JwnF4. 1tl I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on /t permits and and contracts. (�Y 5. I understand if I employ or otherwise engage any y 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. ,Eh , . C I understand if I am considered an "employer" under state and federal taw, 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 iskk7risk- k77. . I 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 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. k'' 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I maybe held 1ia6le for any financial or personal. 4.uries sustained by any subsequent owneF(s) that result from any latent construction defects in the workmanship or materials. R9. 11 understand I may obtain more information regarding my obligations as an "employer" from the Internal RD+enu@ '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 (MM at 1- 800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. 10: 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: I. 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 as well at employers. �V 12` I agree to notify the issuer of this form immediately of any additions; deletions, or chsnW to any of the tnfarmntion I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who doess not have a license,. fie 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 tn'ctvil court. It is also important for you toy understand that if an unlicensed.Contractor or employee of that individual or fum is injur0d wbile wOddng 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 Mwther or not those Cou Tactors are ptopeAy ficensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this fe the agency responsible for is=kbg.Ma.perm1t other verification acceptable to the agency is owner's signature. 1 Signature of property owner tst be completed and signed by the property owner and returned to A copy, of the property owner's dkiveesRwrrse; Form not nj or ped to be presented when the p,?.amit is issued to verify the pmpert)' Date: 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 O"ER'S BEHALF Excluding. the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following persons} to act as my ageat(s) to apply for, sign, and file the documents necessary to obtain ani 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 personhlly filled out the above information and certify its accuracy. Note: A copy. of the owner's driver's license, form notarization, or other verif cation acceptable to the agency is required to be presented rvhen'the permit is issued to verify the property owner's signature.. Property Owner's Signature: Date: 0f , QL1Inta Bullding a Safety Division P.O. Box 1504, •78-495 Calle Tampico La.Quinta, CA 92253 -:(760) 777-7012 Building Permit Applicadoa and Tracking Sheet . Permit # �- Project Address: �� !/ Owner's Name:. 174-E Al VK l,4 A. P. Number. Address: Y Legal Description: City, ST, Zip: ( y- p2a Contractor: Telephone: Address: P ajectDescription: J 1 1 60 City, ST, Zip: Telephone:a asp' State Lic. 4: Arch., Engr., Designer. City Lia C Address: City, ST, Zip: Telephone: State Lia il: Name of Contact Person: Construction Type:. Occupancy: _ . Project type (cu•cle one) New Add'n Alter Repair Demo Sq. Ft.: # Stories: #Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS UNE d Submittal Req'd'Rec'd TRACKING PERMrPFEES- Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Play Cbcck Deposit. . Truss Calet. Called Contact Person Plan Check Balance_ Title 24 Cales. Pians picked up Construction Flood plain plan Plans resubmitted.. Mechanical Grading plan 2" Review, ready for correctionsfissue Electrical. Subeontaetor List Called Contact Person Plumbing Grant Deed Plans picked up S.M L H.O.A. Approval Plans resubmitted Grading IN KOUSE:- ''" Review; ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.LP-P- Pub. Wks. Appr ' Date of permit issue School Fees Total Permit Fees