11-1160 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T -&t 4 4 Q"
Application Number: 11100001160
Property Address: 53205 EISENHOWER DR
APN: 774-055-020-10 -000000-
Application description: WALL/FENCE
Property Zoning: COVE RESIDENTIAL
Application valuation: 1200 .
Applicant: Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
--------------------------------------------- - - - - --
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 ISec. 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, 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.).
(_ 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.).
(_) I am exempt under Sec. , BAP.C. for this reason
Dater = - u — '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 Address:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/21/11
Owner:
JOSE AGUSTIN MENDEZ
53205 EISENHOWER DR
LA QUINTA, CA 92253-----��`
------------------ rz)------. ---
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Contractor: r D.-
aO
Owner i ` .-T 2 `�' 201?
----------------- x..� _
Nr
CITY 0JFZ
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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 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
37000 otthe Labor Code, I shall forthwith co iply with those provisions.
—Date: l� `^' ^ I`_ Applicant:
WARNING: FAILURE TO SECUR WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND 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 correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county tofenter upon the above-mentioned property for inspection purpose
Signature (Applicant or Agent):
r /7c
LQPERMIT
Application Number . . . . . 11-00001160
Permit . . .
WALL/FENCE PERMIT
Additional desc .
Permit Fee . . . .
29.00 Plan Check Fee
00
Issue Date . . .
Valuation . .
1200
Expiration'Date . .
4/18/12
Qty Unit Charge Per
Extension
BASE FEE
15.00
7.00 2.0000
HND . BLDG 501-2,000
14.00
----------------------------
Special Notes and Comments
-------------------------------------------
-----
38 LF X 5' FT CITY
STANDARD BLOCK WALL.
PER APPROVED PLANS.
--------------------------------------------
Other Fees . . . .
-------------------------------
. . . . . BLDG.STDS ADMIN (SB1473)
1.00
Fee summary
Charged Paid Credited
---------------------=--------
Due
-----------------
Permit Fee Total
----------
29.00 .00 .00
.29.00
Plan Check Total
.00 .00 .00
.00
Other Fee Total
1.00 .00 .00
1.00
Grand Total
30.00 .00 .00
30.00
P.O. BOX 1504
LA QUMTA, CALIFORNIA 92247-1504 BUILDING '& SAFETY DEPARTMENT
78-495 CALLS TAMPICO (760) 77777012
LA QUINTA, CALIFORNIA 92253 FAX (760)' 777-7011
PROPERTY OWNER'S PACKAGE
Disclosures & Forms for Owner -Builders Applying for Construction Permits'
[WOR 1YT. d IYOTICI:ToPROPERTY RTY OWNEFt
Dear Property Owner.
An. application for a building your Heine listing yourself pity
adding permit has been submitted is as the builder of the
impriove+ments specified at.
We are prodding you with an Owner -Builder Admwledgment and Information Verification Forst to make you awam of your
respctasibilities and Possible tisk you may incur by issuing thispetaait-sassed M your nAlm as .the
Owner -Builder. We will not Issue a buildingpermit until yan�have read, initialed youranderstauding of each: prevision,
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.
Off 'S AeI
NOWMiDGAWNT AND VE CATM_ QF WOM"TiIMN
DftEC"OAW Read and mural each saarement bdow"te signify you waderstand or very dies utjor mation.
at r l l . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-Buildee'
building permit that erroneously implies that the property owner is providing his or her own labor and material per&onallY. 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 insurancecoverage for injuries to workers
on my property.
a
"-2. I understand building permits are not required to be signed by property owners unlew they are responsible for the
construction and are not hiring a licensed Contractor to assume this responsibility.
3Ai%- 3. I undersrtand as ail "Owner -Builder' I am the responsible party of record on the permit. I understand that I may protec,
myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his er her name instmd of m}
own.
a &h 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers o
permits and contracts.
J At-, 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total Val,
of my construction is at least five hundred dollars ($500), including labor and materials, [may be considered an "eanploye
under state and federal law.
.1 A rib. h understand if .I am considered an "employee" under state and federal law, I must register with the state and fedi
government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemploym
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious finair
risk
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family resides
structures cannot .legally build them with the . intent to offer them for sale, unless all work' is performed by Brei
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is Perim
under contract with a licensed general building Contractor.
_8....1 understand as an Owner -Builder if I sell the property 'for which this: Peru ►u . is issued; I may be held liable for.any.
financial: or personal..4' susfained by any, subsequent owrrer(s) that result from any latent Constriction .defects, in the
woriomanship or materials.
P r9. U understand ' I may obtainmore information mgaidihg.my obligations as an "empioyeei,from •the Internal Rownue
Service, the United States Small Business Administration, the California Department of Benefit'Paymerfts, and the California
Division of Industrial Accidents. l also understand I may contact the California Contractors' State License Board (CSLB) at. 1-
800-321-CSLB (2752) or www.cslb.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
party. legally and financially-, responsible for proposed construction activity at the following address:
1 L I agree that, as the party legally and fially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
agree to notify the issuer of this form immediately of any additions; deletions, or chi to any of the information l
have provided on this form.. Licensed contractors are regulated by laws designed to protect the p0blic. If you contract with
someone who does not have a license. the Cofactors' 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 inVivil court It is also
important for to understand that if au urilioensed Conttaptor or employee of that individual or firm is injured while woddng
on your property, you may be hold H" for damage& If you obtain a permit as Owner -Builder and wiadr to hire Contractors,
you will be responsMo for v=ffYing v&cd m or not those Contractors are properly licensed and the staters of theme workers'
compensation insurance oovenw.
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 issue; thepum ft Note: A copy of trete properg* owner's Muer-'s APO 619sco fwm ft0muka OW4 or
other verification acceptable to the agatcy is requir-ed to be praseited when the permit is iar mi to verify the properly
owner's signature.
Signature of ply owner Date /C) 2 I
4
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.
AUTRORWATION OF AGENT TO ACT ON PROPERTY•'S B F
Excluding the Notice to Property, Owner, the execution of which I understand is myperaomal responsibility, I hereby authociu
the following persons} to act as my agengs) 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 abc
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: /C%
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49' ,CSINGL,� F
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26'=10'
28'=9" I 1 (� KGfNK YNKV \ I 28'=9"
MPA
SCOPE OF WORI
TO 'PRE DAMAGE
.ROOF STRUCTUF
INSULATION, ELE
(E) SINGLE FAMILY DWE
REPAIR FIRE DAMAGE A -
ANY TRUSES W/DAMAGE
(E)FIRST FLOOR 1,443.
TYPE OF CONSTRUCTION
No. OF STORIES : 1
THE TRUSS (
494 S. FOUF
951-922-2�
Bin #
City of La Quinta
Building 8F Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Pe t #
1
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Project Address: S 7 a S i h W.r- ,of—
Owner's Name: Jose u<, -1,^A A eh
A. P. Number: L4 Q v c 4 4 c,-
Address:33 Zo S F-; Sle
Legal Description:
City, ST, ZipLA Qu f o a, CA. 2 2 S
Contractor: Q -e U 1 %11 E' h �t�
Telephone (_
Address:
Project Description:
City, ST, Zip:
Telephone:
X. :.;:::;
State Lie. # : City Lie. #:
Arch., Engr., Designer:
54 -/
Address:
City, ST, Zip:
Telephone: ';`""?:w `2 ::`v^
Biu,::7wR;':ia>:3:;>;c.%r..:�;;: .:;::.: f;•+y
State Lie. #. >:>:><:?:<.>:<»>.>::>. ;;ter; >i.;;f::; s;
< r "' • "�� •vk:,•w.;
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person:
Estimated Value of Project: 2 Q
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
Tide 24 Calcs.
Plans picked up
Construction '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2°" Review, ready for correctionsfissue
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 correctionslssue
Developer Impact Fee
Planning Approval
Called Contact Person •
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees