BELC2019-003278-495 CALLE TAMPICO
c&ty/ 4 4P Qu4A1
LA QUINTA, CALIFORNIA 92253
DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype:
ELECTRICAL- UTILITY (IID) RELEASE (WEB)/
Application Number:
BELC2019-0032
Property Address:
53700 AVENIDA OBREGON
APN:
774115010
Application Description:
MILLEY / 200 AMP BREAKER CHANGEOUT
Property Zoning:
Application Valuation:
$350.00
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
ALEX MILLEY
53700 AVENIDA OBREGON
LA QUINTA, CA 92253
Applicant: Contractor:
REAY GARAYT � ❑ OWNER BUILDER
53700 AVE MONTEZUMA
LA QUINTA, CA 92253
MAR 0 5 2019
CITY OF LAQUINTA Llc. No.:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DESIGN & DEVELOPMENT DEPARTMENT
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 I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professlons Cade: 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 fife a
signed statement that he or she Is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (Commencing with Sectlon 7000) of Division
3 of the Susiness and Professions Code) or that he. or she 1s 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
_�Vas owner of the property, or my employees with wages as their sole
compensation, will da 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
Ahone year of completionthe owner -builder will have the burden of prav€ng that
se did not build or Improve for the purposeof sale.wner of the property,aely _or,"'tgwithlicensed contractors
struct the project. (Sec. 7044, Business and Professions Cade: The Contractors'
State License Law does not apply to an owner of property who builds or improves
t ereon, and who Contracts for the projects with a contractors) licensed pursuant to
ntractors' State License Law.).
I am exempt under Sec. . B.&P.C. for this reason
Owner:
WORKER'S COMPENSATION DECLARATION
Date: 3/5/2019
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:
Carri Policy Number: _
� certify that in the performance of the work for which this permit is issued, 1
all 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 of the Labor Code, 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 to the Building 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 Quint a, 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.
CONSTRUCTION LENDING AGENCY I agree to comply with all city and county ordinances and state laws relating to building
I hereby affirm under penalty of perjury that there is a construction lending agency for construction, and hereby authorize representatives of this city to enter upon the
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). above -``mentioned property for inspection purposes.
Lender's Name:Dd#s! tf -o— �Qf a
fie (Applicant or Agent):
Lender's Address:
Fate: ` 'V5/2019
Application Number:
Property Address:
APN:
Application Description:
Property Zoning:
Application Valuation:
Applicant.--
REAY GARAYT
53700 AVE MONTEZUMA
LA QUINTA, CA 92253
BELC2019-0032
53700 AVENIDA OBREGON
774115010
MILLEY / 200 AMP BREAKER CHANGEOUT
$350.00
Owner:
ALEX MILLEY
53700 AVENIDA OBREGON
LA QUINTA,CA 92253
Contractor:
OWNED BUILDER--
Llc. No.:
Detail: REPLACE 200 AMP BREAKER ONLY LIKE FOR LIKE DOES NOT INCLUDE RELOCATION. PER 2016 CALIFORNIA BUILDING CODES
:.J
A'(VRIJ A :
DESCRIPTION ACCOUNT QTY AMOUNT
ELECTRICAL - UTILITY RELEASE 101-0000-42400 0 $80.05
Total Paid for ELECTRICAL - UTILITY RELEASE: $80.05
W
Q u'N��+ . PERMIT #
PLAN LOCATION:
Project Address: Project Description: Pool, Remodel, Add't, Elect, Plumb, Mech
APN #:
�- Co A. H
Applicant Name: V �A V
Address: O 15
City, ST, Zip: _257
Telephone: G ®n,2�- 3 '7 � 7
Email: Valuation of Project $ C
Contractor Name:
New SFD Construction:
Address:
Conditioned Space SF
City, St, Zip
Garage SF
Telephone:
Patio/Porch SF
Email:
Fire Sprinklers SF
State Lic: City Bus Lic;
Property Owner's Name: A Lex
Address: �.?7 0 I, 6:�UJ , 0� _ /
City, ST, Zip �� (V J ",V to 6-/?
Telephone: O —,9S 7 4
Email: AL IF . Lie VP VA L r7 . r
New Commercial / Tenant Improvements:
Total Building SF
S3 Construction Type: Occupancy:
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
,
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understand'as an flvnler-Builder if :F sell :the: property fox which this 0 rMit Is issued, I rrsAy he held liable for any
financial or personal. injuries sustained by any subsequent awnc1.6) that result from ally latent construction defects in the
workmanship or nlaterids�,
... - r . - ::�,:.-- .: ...
I tnderstand 1 .riiay'vTitaiii'`rnpi `iii%iinahan regarding: ttty abligatinxts as an "employer" .from the info k�Ftsvcnue
Service, the United States. Small Business Administration, the California Depadrncut of -Benefit.paymcnts, and fit slitorrzia
Division of Industrial Accidents..I also understand I may contact the California Contractors' State, Licensa.Beard CSL� at. l-
c y.
800-321-CSLB (2M) or Nvww.cslb.ca.gov for more information about licensed contractors. �,,,;,x c ai3a ?'s N
10. Tarn aware of and consent to an ❑wnm-Builder building pernut applied for in my name, and understand that I amYtile
part�-7 legally. and: financially responsible- for proposed constructiGn..`: activity at 'the following. address:
`7r95 4.' w,.3 i_ iJ�i•v _tVl.� (� z. c
I agree that, as the pa4legally and financially responsible -for this proposed coustruction aetivity; J will abide by all
applicable laws and requirements that govern Owncr-Builders as wcli as employers.
- 12, 1 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..i.iccnsed contractors are regulated bylaws designed to protect the. public. If:you. contractwith
,�• :,.$ . sortieone who does not have a licr�tsc,.thc Contractors' State License 9 ard.iriaybe =al7lc to.assist yoit with any financial foss
You May sustain as:a result of a complaint. Your onl reined :a ainst. unlicensed Contractors may be in civil: coo .. It is also '
important for you to understand that lion tinticensed Contrs.?rp i ernp 0yee of that indivir3ual or firm is injured while Working
an your property, you inlay beheld liable for darni<xges. If you obtain a prmur as Owner -Builder and wish to hire Contractors,
` you willbe responsible for.verifyitig whether or. not those. Contractors are .property licensed and the status of their workers'
compensation insurance coverage.
e[ore a building hermit cstn lit: issued, this Farm Must be cum r eted'arid si 'rie� b the- 0o er -wner.a d reiurne
- �issuingl 15 .. Y F P.. t3'. a n and d to
+ :•
the agency responsible for #lte permit: Note: A copy of the property piwner's driver's license, forin iwWixntion, or;.
other verification acceptable to the agency is. required ry be:: resealed suhen rlre Permit 1s issued to verl tFt,erp �r
a r>arrer s signatur'e., u P p i3' p P t'
- ,.
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5igna
Date: tur�e of p p riy Owner
r0 e _
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No
fie. pitefallo�ving�luthoriatirrn Form iti.re required to be..carn _°....:...:.......;:. :.::.
r! pleted by �hlnroperly..nrvner Dirty suher:. dcstgnattng
.;: an agent of the properly owner to.apply. far• a connrurtiorz permit for tine 3lvirer- 8rrilcder:. w..
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_ _ v�_ ... � v ..�. ,� vx• 1 1\lJiL' IS.1 x ii�,t�IM{!�-'��r,�•t!� rP.`''-,"".-.;�°-,,.`-_.--�..,,[---°_-'�_''
Excluding .the.N.o>xce to Proper[y:tJ►+i er, the exeeutiati of Which I understand is-iny peisarial iesporrsibility„1 hereby aittlsori2
the following persrin(s). to act as .ruy.agen#(s) to applyfor, sigst, and File the daGurnents nccesssiry to obtain an C]�vriu#_Builder
Permit for my project.
scope ofConstiruction Project (or Dcscriptibn of Work)- 4 Ct_ ��
t-�- - --Lk
Project Location ar Address: m4,c,,j 1± d
�_s1q ►�. Orr et'» r_
Name of Authorized Agent: � � ~ ,
„.� '• _ 7�_
Tel No
�_ � _' � �� R-�•
Ad rr ss.nfA�ttltorized Agent: 53. r U 1� ► v t PA li",
-,:,I declare urider.peualty of perjtuy that.I am the property avirrter far the addle iistt d alioNc and:I ens information and and certifyits accuracy, Not`ei A co p onally filled out tlic-abate
Y-' llCCCfJIRlJ]8. } .ti7i RgCTiL'y 2S 1'E{iirrl('Gl tp be pres'n d hea the permit is issued ca v ris license, �,�.: notarixgtir�ri, or pi{:er verrfieation
f� the p .op r #y oh�rer s sigriuttir e. .
'ropeity.0►vner's .Szgriatstrc::.
.+d' � _ � :c� ; r;>--' �k, '.',�� > •ems: _ - •:. ;+