BWFE2017-0164rp' �
78-495 CALLS TAMPICO D VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011DESIGN & DEVELOPMENT DEPARTMENT
.INSPECTIONS (760) 777-7153
BUILDING PERMIT
Application Number:
BWFE2017-0164
Owner:
Property Address:
44345 MARIGOLD LN
ABDULMASS H DOURGHALLI
APN:
604093003
i
44375 MARIGOLD
Application Description:
DOURGHALLI / 72 LF AT SOUTH PL W/ GATE
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
$4,800.00
Applicant:Contractor:
�n
ABDULMASSIH DOURGHALLI
D /L1\
OWNER BUILDER
44375 MARIGOLD
"� U
LA QUINTA, CA 92253
2017
AUG 2qNTA
COMMUNITYDEV�EL0pA4EM
Llc. No.:
EPARTMENT
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 Professions 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 1 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 thefefrom and the basis for the
alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
As s the applicant to a civil penalty of not more than five hundred dollars ($500).:
� `was 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
oh lid not build or improve for the purpose of sale.).
FO ?as owner of the property, am exclusively contracting with licensed contractors to
c nstruct the project. (Sec. 7044, Business and Professions Code: The Contractors' State
License Law does not apply to an owner of property who b.uilds'or improves thereon;
and who contracts for the projects with a contractor(s) licensed pursuant to the
.Liftitractors' State License Law.).
M-11% exempt under Sec. BAP.C. for this reason
Date:w -Ab _Owner• E
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
Lender's
Date: 8/29/2017
WORKER'S COMPENSATION DECLARATION ' .
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certiftate of consent to self -insure for workers'
compensation, as provided for by Section .,700 of the Labor Code, for the performance
of the work for which this permit is issued.
I have and will maintain worker' compensation insurance, as required by
Section 3700 of the Labor Code, for the pe -formance of the work for which this permit is
issued. My workers' compensation insurance carrier and policy number are:
Carrie Policy Number: _
t T '_;certify that in the performance of the work for which this permit is issued, I
II not employ any person.in any mannee so as to become subject to the workers'
compensation laws of California, and agree that, if I sho Id become subject to the
workers' compensation provisions of Section 3700 of a Labor C e, I shall forthwith
comply with those provisions.
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 b the Building Official for a permit subject to
the conditions and restrictions set forth orrthis 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 Cty 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 6suance 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 r ating to building
construction, and hereby authorize representatives of this city r uppot bove-
mentioned property for inspection purposes.
Date:. 8/29/2017
Application Number: BWFE2017-0164 Owner:
Property Address: 44345 MARIGOLD LN ABDULMASSI-1 DOURGHALLI
APN: 604093003 44375 MARIC OLD
Application Description: DOURGHALLI / 72 LF AT SOUTH PL W/ GATE LA QUINTA, CA 92253
Property Zoning:
Application Valuation: $4,800.00
Applicant: Contractor:
ABDULMASSIH DOURGHALLI OWNER BUILDER
44375 MARIGOLD
LA QUINTA, CA 92253
Llc: No.:
--------------------------------------------------------------------------------------------
Detail: 72 LF OF 6' GARDEN AT SOUTH PROPERTY LINE WITH GATE [CITY SPECIFICATIONS] PRECISION CONCRETE ELOCK SHALL BE COVERED WITH
STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF CURB AND ANY FENCING
SHALL BE LANDSCAPED; HAVE A SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016
CALIFORNIA BUILDING CODES.
DESCRIPTION
FINANCIAL •• •
ACCOUNT QTY
AMOUNT
WALL/FENCE - FIRST 100 LF
'101-0000-42404 0
$50.67
DESCRIPTION
ACCOUNT QTY
AMOUNT
WALL/FENCE - FIRST 100 LF PC.
101-0000-42600 0
$63.33
Total Paid for BLOZ'K WALL:
$114.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306
0
$1.00
Total paid for BUILDING STANDARDS ADMINISTRATJON BSA:
$1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
+ + N er V
A AP
•
Bin#
City of La Quinta
Building & Safety Division '
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit#
d'di•ess:�
Project"A�'
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..... - - L
Owner's -Nam
A.P. Number
Addresser `/„ J
`—t'c t
City p lAq,n
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i
3 "
Legal Description:
Contractor: O A y�,fJ/)
Telephone:
Address:.
Project - Description
Lam'AA
City, ST, Zip:
Telephone:
I "
State Lic. #:
City Lic #:
Arch, Engr., Designer:
Address:
City, ST, Zip:
Telephone:
Construction Type:
Occupancy:
State Lic. #:
Proj. Type
NewAdd'n
f#Storie,
Alter
Repair
Demo
Name -o£ -Contact: 7
evin
cam'
SgFt:
# Units:
Telephone -of Contact:
�0,0Estimated"Value
of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Ree'd
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:
Title 24 Calcs
Plans Picked Up
Construction:
Flood Plain Plan
Plans Resubmitted
Mechanical:.
Grading Plan
2nd Rev, Ready for corrections /
Electrical:
Subcontractor List
Called Contact Person
Plumbing:
Grant Deed
Plans Picked Up
S.M.I.
HOA Approval
Plans Resubmitted
Grading
IN-HOUSE
3rd Rev, Ready for corrections /
Developer Impact Fee
Planning Approval
Called Contact Person'
A.I.P.P.
Pub. Wks. Apps
Date of permit issue
School Fees
Total Permit Fees
Malcolm D. Maxsted f�
44375 Marigold Ln.
La Qinta, CA 92253
P.D. BOX .1504
LA QUINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT
78-495 CALLS TAMPICO (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
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 -wilder of the property
improvements specified at
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 owner 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 signily 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"
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 ':)y an unlicensed person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
limits injuries. I am willfully acting as an Owner -Builder and am aware of the its of my insurance coverage for injuries to workers
on my property.
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
myself from potential'financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
,C% .fl 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
1145. I 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 may be ccrosidered an "employer"
under state and federal law.
406. I understand if I am considered an "employer" under state. and federal law, I must register with the state and federal
goverment, withhold payroll taxes, provide workers' compensation disability insurance; and contribute to unemployment
compensation foi• each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
4-0 7. 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.
"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 injuries sustained by any `subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
,Q & 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 respo"nsible/ for proposed construction activity at the • following address:
'moi tri
,A -R11. I agree that, as the party legally and fmancially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern -Owner -Builders asmell as employers.
4 -2 12. I agree to notify the issuer of this form immediately of any additions,.deletions, or changes to any of the information I
have 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
overage:Before a building permit canbe 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 agency is required to be presented when the permit is issued to verify the property
owner's signature.
Signature of property owner Dater
Note: The following Authorization Form is required to be completed by theproperty 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): (GC
Project Location or Address:
4� 5�43�5
Name of Authorized Agent: 11�;14fz, Tel No
Address of Authorized Agent: J ,S `4 60 IAVI
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 when the permit is issued to verify the property owner's signature.
Property Owner's Signature: Date: