BPLB2017-0146M
ao. VOICE (760) 777-7125
78-495 CALLE TAMPICO ++ Ct 4ht D !a .
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 11/7/2017
Permit Type/Subtype: PLUMBING/ Owner:
Application Number: BPLB2017-0146 WILLIAM MALIK
Property Address: 51100 CALLE .QUITO 118 S CALLE, ALTA
APN: 770144010 ORANGE, CA 92869
Application Description: MALIK / NEW GAS SERVICE FOR ENTIRE HOME
Property Zoning:
Application Valuation: $3,000.00
Applicant: Contractor:
WILLIAM MALIK ® OWNER BUILDER
118 S CALLE ALTA
ORANGE, CA 92869 NOV ® 7 2017
CITY OF LA QUINTA
DESIGN AND DEVELOPMENT DEPARTMENT Llc. No.:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjurythat J 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 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
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 polity number are:
C rrier: Polity 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 3700 f the Labor Code, 1 shall forthwith
comply with those provisions.
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 ,
Date: > Ap Y/
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
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
as owner of the property, or my employees with wages as their sole
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
compensation, will do the work, and the structure is not intended or offered for sale.
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does not
INTEREST, AND ATTORNEY'S FEES.
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
APPLICANT ACKNOWLEDGEMENT
are not intended or offered for sale. If, however, the building or improvement is sold
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
within one year of completion, the owner -builder will have the burden of proving that
the conditions and restrictions set forth on this application.
he did not build or improve for the purpose of sale.).
1. Each person upon whose behalf this applicarion is made, each person at whose
-to- , as owner of the property, am exclusively contracting with licensed contractors
request and for whose benefit work is performed under or pursuant to any permit
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
issued as a result of this application , the owner, and the applicant, each agrees to, and
State License Law does not apply to an owner of property who builds or improves
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
employees for any act or omission, related to the work being performed under or
,4th _ ntractors' State License Law.),
�am
following issuance of this permit.
exempt under Sec. & C this g�
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
Lt
7ALt
r"f
for 180 days will subject permit to cancellation.
CONSTRUCTION LENDING AGENCY
'I hereby affirm under penalty of perjurythat 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
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 represen atives this cienter upon theo
above-mentioned property for' i p
Date: 11/7/2017
Application.Number: `
Owner:
Property Address:
:7BPLB2017.0146
51100 CALLE QUITO
WILLIAM MALIK'
APN:
770144010
118 S CALLS ALTA
Application Description:
MALIK / NEW GAS SERVICE FOR ENTIRE HOME
ORANGE, CA 92969
Property Zoning:
Application Valuation:
$3,000.00
Applicant:
Contractor:
WILLIAM MALIK
OWNER BUILDER
118 S CALLE ALTA
ORANGE, CA 92869 '
---------------------------------------
----------------------------
Llc. No.:
--------------------------
Detail: NEW GAS SERVICE. GAS RE-PIPE ENTIREHOUSE: DRYER, WH, COOK TOP, AFU, FIREPLACE, AND FUTURE BBQ. PEF. 2016 CALIFORNIA PLUMBING
CODE.
FINANCIAL •• •
.-'DESCRIPTION ACCOUNT QTYAMOUNT
ACCOUNT
BSAS S61�473 FEE • 101-0000-20306 0 $1.00
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
0
$5.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$98.83
Total Paid for PERMIT ISSUANCE: $98.83
DESCRIPTION
ACCOUNT
QTY
AMOUNT
GAS SYSTEM, 5+ OUTLETS
101-0000-42401
0
$39.01
DESCRIPTION
ACCOUNT
QTY'
AMOUNT
GAS SYSTEM, 5+ OUTLETS PC
101-0000-42600
0
$26.01
Total Paid for PLUMBING FEES: $65.02
DESCRIPTION
ACCOUNT
QTY_ .
AMOUNT
RECORDS MANAGEMENT FEE
101-0000-42416
0
$10.00
Total Paid foi RECORDS MANAGEMENT FEE: $10.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00,
I''°,
New SFD Construction:
PERMIT #'
Conditioned Space SF
City, St, Zip
PLAN LOCATION
Y
Patio/Porch SF
Projeet Ad.r1- ss- /1
Prod ject Descrijit'i-on:4�Pool; Remodel Add-t;�Elect; Plumb ech
APN #: -
State Lic: City Bus Lic:
C, ! fV F_
L ek �� ►�
�r_A-liptrcant��W I L -L / 4Nt %' I 14'L
7— -64u //V7-0 &Ax -7't ,6E
!Addr-e s� s_f+
City,�ST;.Zi
g
`
-
EEiin�ai+l Q/i �io �Q
��/� �
as��alua'tion-df Project -$-
Cont•r� a� cto 'Name;_ 1�L�
New SFD Construction:
Address:
Conditioned Space SF
City, St, Zip
Garage SF, ,
Telephone:
Patio/Porch SF
Email:
Fire Sprinklers SF
State Lic: •� City Bus Lica'
Arch/Eng Name: _
Construction Type: Occupancy:,
Address:
Giading:
City, St, Zip
Construction Type: Occupancy.
•y
Telephone:
Bedrooms:
Stories:'
# Units:
Email:
State Lic: City Bus Lic:
t
Property Own:er�s�Name��YI
4Add�'mess
+-TEl.ephon
New Commercial/ Tenant Improvements:
y � s. C - L ez—
Total Building - SF
City, ST-zi
Construction Type: Occupancy.
` l• -,)2 —62-
6Z 2
T.
E
78495 CALLE TAMPICO
LA QUINTA, CA 92253
` 760-777-7000
. J
c
R F-L W,
OK
e 1
90
F/p 3B 4
2
lig C-ITY OF LA QLKTA
t i BUILDING & SAFETY DEPT.
APPROVED c
FOR .CONST CTION V
DATE �� I
• � adz � � - .
�S�'�►VAN
coP� 5iinn CALL9 t2u'
I ro
P.O. BOX 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
W
BUILDING &- SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying forConstrucB:ion Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building t has bM ed 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 _hake 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 signify you understand or verify this information.
01. 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. 1, 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.
u rte`. 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.
Nom. 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 fier name instead of my
own.
. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
L461M. 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 cori:idered an "employer",
under state and federal law.
kJ47f4 I understand if I am considered an "employer'.' under state and federal law, I must register witE the state and federal
government, withhold payroll taxes, provide workers' compensation disability insurance, and contribite to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
�-M 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 tLe work is performed
under contract with a licensed general building Contractor.
.` v
jA8. 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.
W ;t. 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.
0. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand thatI am the
party legally. and financially responsible , for proposed construction activity at the following - address:
agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all.
applicable laws andrequirements that govern Owner -Builders as.well as employers.
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 bylaws designed to protect the public. If you contract with
someone who. does not have a license, the Contractors' State License Board maybe 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 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 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):
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 other verification
acceptable to the agency is required to be presented when the pernnt is issued to verify the property owner's signature.
Property Owner's Signature: Date:
CITY OF LA QUINTA SUB -CONTRACTOR. LIST
JOB ADDRESS
`the
__ PERMIT NUMBER _ OWNER f „BUILDE(�
-in acc. Only—persons appearing on this list or their employees are authorized to work
This form shall be posted on the iob wiih Building
Inst�ection Card at all times a consnictlous. �)4
on this job. Any changes"to this ,list must be approved
by. the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of permit. For each applicable trade; all information requested below must be completed by-opplicant.. "On File" is not an .acce.ptable response
.building
..... ... .:.. .. , .
.. .,.. ., _ ...•
_.
::............... • .:. ....... .:.: ....
t
o. .... .......
.,,.:..>:. -:... �.... . _ � ..:.,..
State Contractor
rkers C iii �cn a ion )ns...a •�.
'13'
LicGnYe ...
-r C Ips snc�auon
Tr c
Ontrac r
C Q
...
Company Name
Classification
License Number
Exp. Date
Carrier Name
Policy Number
. Exp. Date
License Number
Exp. Date _
(e.g. A, B, C-8)"
(xxxxxx)
(xx/xx/xx)
(e.g. State Fund, CalComp)
(Format Varies)
(xxlxx/xx)
(xxxx)
(xx/xx/xx)
1yF�F:ThiWOFtK(C 12)
—
MINNG (C'S) x
'
"STRUCT STEEL (C ri1.}
lVIl15ONRy (C 29)
PLUMBING IC. 36}
oU%N-F- I L
..
°,HUAC fC 20)
%�LEGTRICl1L.(.C;=7,'a)��»�•
,
>SF))wFT:IV(ETlIL (G 43)r`
—
—
'FLOORING (C 16) .,
'
GLAZING (C 17)
_
t
Il11SU�ATlOt1( (C 2)
'
;SL1NlaG� D1SP (C �2j
>irEl 'AIVII,G?TI.LE:.(C;
-
----
Project ID 00000209423.
'xhibit A,
SOUTHERN CALIFORNIA GAS CO.
:E CALCULATION (ESTIMATES)
**** PAYMENT RECEIPT ***+**
11/3/2017 4:05:14 PM
TP2EMM y730751017 0089
5144 INDIO as Only Trench
ISMS PROJECT 209423
10142.036 $3.752.93
ILLIAM MALIK $ 0.00 = $ 3076.17
18 SOUTH CALLE ALTA Allowance Applied
NNE CA 92869-
'OTAL
$� 00
$3,752.93
:ASHIERS CK $3.752.93
$ 3076.17
:HANGE $0.00
X 2 % _ $676.76
'YPE OFFICE
SAVE TIME. DO MORE ONLINE_ $0.00
iO TO MYACCOUNT_SOCALGAS_COM
TO VIEW. PRINT, & PAY. YOUR
BILLS ONLINE.
$ 3752.93
THANK YOU
applicant provided trench will be treated per
ts, if any, will be based on the agreed upon
price per foot times the actual footage of the trench used.
Form 3905-D, Effective 09/05 Line Extension Contract #: 00000209423-1
Detach and return this portion with your payment.,
Date Mailed
10/17/2017 THIS BILL IS NOW DUE AND PAYABLE
,� WILLIAM MALIK
G.
118 SOUTH CALLE ALTA
ORANGE, CA 92869
NBMS Project ID 00000209423-1
PLEASE PAY THIS AMOUNT
9200020942301000000037529300000 92 000209423 0
Line Extension Contract
Project 209423
The
Gas
.Company
A ,Sempra Energy utility'
Applicant: ' Malik**William*" Fax: 0
Contact: William Malik Tel: 7146026228
From: JORGE CAZARES Fax: 7607739243
Address: 75095 MAYFAIR DR
Email Address: JCAZARES@SEMPRAUTILITIES.COM City/ST/Zip: PALM DESERT CA `32211 5102
Tel 9093357634
Date: 10113/2017
The project planning and cost estimating for Project# 209423 has been completed and included
with this letter. Under the Line Extension Rules, you have agreed to have SoCalGas perform the
following gas facility installation:
service.and.meter. Applicant provided gas only trench that SCG will back fill.
SoCalGas estimated construction costs, (prior to applicable allowance, site area fees & taxes) are broke -.-i
down as follows:
Main
0
Stub
- 0
Service
2681.55
MSA
409.62
Please execute vour Line Extension contract and return by email or fax to the followin
Email: NBProcess-Inland@semprautilities.com
Fax: 1-866448-3821
• If payment is due, please remit payment with Exhibit A Stub to:
Southern California Gas Company
Sundry Billing ML Z11 D
P.O. Box 2007
Monterey Park, CA 91754-0957
Construction cannot begin until your signed Line Extension Contract documents
and payment have been received and recorded by SoCalGas..
If you have any questions regarding this matter, please reply via'email or fax to the above' listed.
Thank you,
Southern California Gas Company
New Business Process Team
SCG Cover Sheet