11-0663 (ELEC)App(liiccaant�:'/ 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 (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) of
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
a �Pplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
r YI, 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
n improve for the purpose of sale.).
T 1 _ `1, 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 La).
Iyam exempt under Sec.----� , B.&P.C. for this reason
� Date:.�hC111711/ L Owner.,. 4 ...i.�.
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: 6/17/11
Owner:
JONES ROBERT .
78835 WAKEFIELD CIR
LA QUINTA, CA 92253'
(760)772-2483
ipContractor: q
Owner
JUN 1 L 201
4 z rry nF L11 QUINTA
-----------------------------------------------
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
37 0 of the Labor Code I she[ rthwith cor ply wit a provisions.
Y Date: [ Applicant:-- '' ti
WARNING: FAILURE TO SECURE 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 auth rize representatives
of this county
�to/enter upon the above-mentioned gropertJy for ins
0&tion
/ purposes.
Date. / ...Signature (Applicant or Agent):
P.O. BOX 1504
78-495CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
111-0000.0663
Property Address:
78835 WAKEFIELD CIR
APN:
604-431-001-9 -23995 -
Application description:
ELECTRICAL'
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
300
App(liiccaant�:'/ 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 (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) of
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
a �Pplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
r YI, 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
n improve for the purpose of sale.).
T 1 _ `1, 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 La).
Iyam exempt under Sec.----� , B.&P.C. for this reason
� Date:.�hC111711/ L Owner.,. 4 ...i.�.
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: 6/17/11
Owner:
JONES ROBERT .
78835 WAKEFIELD CIR
LA QUINTA, CA 92253'
(760)772-2483
ipContractor: q
Owner
JUN 1 L 201
4 z rry nF L11 QUINTA
-----------------------------------------------
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
37 0 of the Labor Code I she[ rthwith cor ply wit a provisions.
Y Date: [ Applicant:-- '' ti
WARNING: FAILURE TO SECURE 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 auth rize representatives
of this county
�to/enter upon the above-mentioned gropertJy for ins
0&tion
/ purposes.
Date. / ...Signature (Applicant or Agent):
Application Number a1-00000663
Permit ELEC-SERVICE CHANGE,
Additional desc .
Permit Fee. 33.50 Plan Check. Fee
.00
Issue Date Valuation . .
0
' Expiration Date 12/14/11
Qty Unit Charge Per'
Extension
BASE FEE
15.00
1.00 18.5000 EA ELEC SVC <=600V/<=200A
18.50
---------------------7---------------7--------
Special Notes and Colmnents
ELECTRICAL METER CHANGE OUT 200 AMP
_
PANEL SAME FOR SAME.
-----------------------------------------------------------------------------
Other Fees . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited -
Due
Permit Fee Total 33.50 .00 .00
33.50
Plan Check Total .00 .00 .00
.00
Other Fee Total 1.00 .00 .00
1.00
Grand Total 34.50 .00 .00
34.50-
LQPERMIT
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Box. 1504
�UINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT
195 CALLE TAMPICO 760) 777-70 12
i.^ yUINTA, CALIFORNIA 92253 FAX 760) 77.7-7011
PROPERTY OWNER'S PACKAGE
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 ahe property
improvements specified at
i 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 own -r cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below.to signify you understand or verify this info- mation.
1. I understand a frequent' 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. 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.
(�__33. I understand as an "Owner -Builder" I am the responsible party of record on the permit.. I understand that I may protect
myself from potential financial risk by hiring a licensed Contractor, and having the permit filedin his or her name instead of my
own.
qf4. I understand Contractors are required by law to be licensed and bonded in California and :o list their license numbers on
permits and contracts:
P;S�5. 1 understand 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 ma} be considered an "employer"
uridei state and federal law.
f6. I understand if I am considered an "employer" under state and federal law, 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
risk.
'd7. I understand under California Contractors' State License Law, an Owner -Builder who -wilds single-family residential
g Y
structures cannot legally build them with the intent to offer them 4or sale, unless all w3rk is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, cr all of the work is performed
under contract with a licensed general building Contractor. ,
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.
_69. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
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 (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 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
app icable laws and requirements that govern Owner -Builders as well as employers.
Q, 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
ha a 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 agen is require o be presented when the permit is issued to verify the property
owner's signature.
Signature of property own Date:
7 -
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): 20 Z) 4A-1 y98 K
Project Location or. Address: % 8 9 3 5— W -r. Ke- 4sW ('r cl qwyif-� CA - ,5 ZZS3
Name of Authorized Agent: At 'f0 tLy - C " C/ _A Tel No _760 — Q�'f ' 6 f g L
Address of Authorized Agent: F_ 1 ` l S/ /C'r Io-_1Ai— l/; e W �r¢, Y_,-1--, CA , FLz o/
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 isArequireepresent when t i ' issued to verify the property owner's signature.
Property Owner's SignaturDate: 7 ��
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 latery construction defects in the
workmanship or materials..
_69. I understand I may obtain more information regarding my obligations as an "employee" from the Internal.Revenue
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 (CSLB) at 1-
800 321-CSIJB (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 as the following address:
61c
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all'
able 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 information I
ha a 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 agen is require o'be presented when the permit i� issued to berify the property
owner's signature. f
Signature of property own 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 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): �P �Actc•� �- 9 O a .},L.,p /� A::.h �d ►� c r ,
Project Location or. Address: g 3 �/�� �Ce �(d ('r (�t,�Yl� �i ' C� 07 z2S3
Name of Authorized Agent: .144 to i1:y G , C C /�� Tel No 7(c — Q�� - 6 OF L
Address of Authorized Agent: Cit L Z o/
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 notari:ation, or other verification
acceptable to the agency is requir o e present when t i issued to verify the property owner's signature.
Property Owner's. Signature: Date: �� J�
Bin #
City of La Quinta
Building 8i Safety Division
P:O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: g
Owner's arae•il� EF
Itie/ M
A. P. Number:'
dress: ? �O�jS�bt%��C2iPfd C►�
Legal Description:
—
City, ST, Zip:
ontractor.. 41i
r` ✓ %
Telephone: . 6 7 7 a.� L( 3
a:Ez�ro:.fi:
s.. :.
Address:
Project Description:
City, ST, Zip:
Telephone:
State Lic. # : City Lie. #;
Arch., Engr., Designer.
Address:
City, ST, Zip:
w. ��£�,�s�,: ;...:<�<•: ya>�vn
Construction Type: Occupancy:
'
MoProJect type icircle one) New Adc'n Alter ar
Sq. Ft.: #Stories: #Units:
"Telephone:
State Lic.
Name of Contact Person:
Telephone # of Contact Person: L
Estimated Value of Project: �
r
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
Structural Calcs.
Reviewed, ready for corrections O
Plan Che k Deposit
Truss Cales.
Called Contact Person
Plan Che:k Balance
Title 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2'! Review, ready for correctionstiissue
Electrical
' Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
3'A Review, ready for correctionstissue
Developer Impact,Fce
Planning Approval
Called Coot act Person
A.I.P.P.. -
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees