BPLB2017-0109M
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
c&tr 44vQabtrw
DESIGN & DEVELOPMENT DEPARTMENT
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
BUILDING PERMIT
Application Number: BPLB2017-0109
pp DOwner:
Property Address: 80083 PALM CIRCLE DR �RK WATKINS, 1H D
APN: 600080037 AUG 14 2017 89083 PALM CIRCLE DR
Application Description: .WATKINS RESIDENCE / GAS LINE IAF t QUINTA, CA 92253
Property Zoning:
Application Valuation: $400.00 CITY OF LA QUINTA
DESIGN AND DEVELOPMENT DEPARTMENT
Applicant: Contractor:
MARK WATKINS, PH D OWNER / BUILDER
80083 PALM CIRCLE DR
LA QUINTA, CA 92253
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 {commencing with Section 70001 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 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).:
(�; 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.).
C:::),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 Contr ctors' State License Law.).
exempt under Sec. . B.&P.C. for this reason
Dam ted, Lal
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. 3091, Civ. C.).
Lender's
Lender's Address
Llc. No.:
Date: 8/14/2017
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 w. 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 3760 of the Labor Code, I shall forthwith
comply with those provisions.
WARNING: FAILURE TO SECURE WORKERS' COMDENSATION COVERAGE 15 UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINA:- PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000)i IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWIEDGEMENT
IMPORTANT: Application is hereby made to the Cuilding Official 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 issaance 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 city to enter upon the
above-mentioned property for inspection purposes.
Da�te:-__j1444/7t-�/7 Signature (APPlicant-or..a )� --
Date: 8/14/2017
Application Number:
BPLB2017-0109
Owner:
Property Address:.
80083 PALM CIRCLE DR
MARK WATKINS, PH D
APN:
600080037
80083 PALM CIRCLE DR
Application Description:
. WATKINS RESIDENCE/ GAS LINE 15 LF
LA QUINTA, CA•92253
Property Zoning:
Application Valuation:
$400.00
Applicant:
Contractor:
MARK WATKINS, PH D
OWNER / BUILDE2
80083 PALM CIRCLE DR
LA QUINTA, CA 92253
-----------------------------.--------
-------------------------------------------------
Llc. No.:
Detail: INSTALL 15 LF OF
1/2' GAS LINE. PER 2016 CALIFORNIA BUILDING CODE.
-------
• FINANf IAI INFf1RMAT1�1N
DESCRIPTION
ACCOUNT CITY AMOUNT
BSASSB1473 FEE
101-0000-20306 0• $1.00
Total Paid for BUILDING STANDARDS ADMINISTRATIOV BSA: $1.00
DESCRIPTION
ACCOUNT
CITY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$96.27
Total Paid for PERMIT ISSUANCE: $96.27
DESCRIPTION
ACCOUNT
CITY
AMOUNT
GAS SYSTEM, 14 OUTLETS
101-0000-42401
0
$12.67
DESCRIPTION
ACCOUNT
CITY
AMOUNT
GAS SYSTEM, 1-4 OUTLETS PC
101-0000-42600
0
$25.33
Total Paid for PLUMBING FEES: $38.00
DESCRIPTION
ACCOUNT
CITY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
TOTALS: 1
BIn.#
City of La QUlhta
Buff ft 8r Safety Division
P.O Bax 1504,78-495 Calle Tampion
La.Qubxa, CA 92253 -:(760) 7777012
Buiift Permit Application and Tracking Reet
Permit #
ProjectAddmm-
80083
Palm Circle Drive, La Quinta, CA oana•s � Mark L. Watkins, Ph.C.
A p. Nwnb
600-080-037-B Address
1.
80083 Palm Circle Drive
Legal Des«;pa of 26 of Tract No 4518, .La Quinta
City, ST, Zip: La Quinta, CA. 92253
Telephone: 760-399-0376
Project Description:
Contractor. Owner/builder
Address:
Ciry. ST, Zap:
Extend gas line along exterior.of building approximately 15'
Telephone:
State Lic. #: City Lic #:
from-gas meter to laundry room and kitchen.
ArcA, Bug, Designer.
Address:
City., ST. Tap: _
Telephone: C=LstruWon Type;
stick built
occupancy sin le famil
Stats Lie. #: Project type (curdle one): New Add'n . ter Repair Deow
Name of Contact Person: Sq. FL: # Stories: 1 # Unity 1�
Tekphoae # of Canted Person Dr. Mark Watkins
Estimated Vahw of Pmjec °✓p -
APPLICANT: DO NOT WRITE BELOW THIS UNE
N
Submlttal
ReWd
Rev'd
TRAC MG
irER?dXTFF.FS-
Plan Sete
Pim Chak Ubmit"
Item Amount
Simetatai Cales
Reviewed, lady for eon-eedons
Plan Cbeck Dewst. .
'Mass Calves.
Called Contact Pen=
Plan Check iia -nee
Title 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted.'.
Mccharilnl
Grading plan
2'! Red ew, ready for eorrec6anarwue
1Rect itdN
SobeontaMr I.6t
CAW Contact Person
Plumbic
Grunt Deed
Plana pidred op
SAA
ILOAL Approval
Plans reaabmitted
Grading
IN MUM-
"R-lew, ready for awredlonsAssue
Developer Impaet Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. Appr
Date of permlt Issue
School Fees
Total Permit Fees
4 4a�w
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 -Builders Applying, for' Construction Permits
IMPORTANT/ NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has bee s bniitted in your name listing yourself as_ t�buil er of the prope
improvements specified at a I
;�� S?3117
We are providing you with an Owner Acknowledgment and Informatio 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
/DIII'RECTIONS: Read and initial each statement below to signs you understand or verify this information.
/ di/ 1. I understand a frequent practice of unlicensed persons is to have the property owner obain 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 m property.
2. I understand building permits are not required to be signed by property owners unless the Y are responsible for the
cco�nstrs ion and are not hiring a licensed Contractor to assume this responsibility.
Jy 3. 1 understand as an "Own -
er Builder" I am the responsible party of record on the permit. I understand that h 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
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
T5.
ts a contracts.
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 considered an "employer"
under state and federal law.
6�Iderstand if I am considered an "employer" under state and federal law, I must register with the stat
taxes g e and federal
government, withhold
payroll ,provide workers' compensation disability insurance; and cont-ibute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subjec. me to.serious financial
risk. :;�/71'understand under California Contractors' tractors 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.
1
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.
/^'►'/ 9. 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-
80/0321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
80-3
'�" 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 legallyp : and financially responsiblS. for ' proposed construction . activity at titre followin address:
OP/i ?I ��, i, 1. 1p � /, , �_1 / _ /; , , �,�.r 1.11 .6 17---f— 7 g
" 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
applile 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 tc• 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 ycu 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
ori your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and. Nish 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 agency is required to be presented when the permit is issued to verify the property
owner's signature.
Signature of property owner. -'' "
Date:
Note: The following Authorization Form is required to be completed by the property owner ouly 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 personally filled out the above
information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or ether verification
acceptable to the agency is required to be presented when the pernut is issued, to verify the property own=r's signature.
Property Owner's Signature: Date:
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<--------------------- 15' 2"---------------------->1
CITY OF LA QUpNTrA
BUILDING & SAFETY
Appy R ED
FOR C0�1S
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