BCOM2018-004678-495 CALLE TAMPICO T4bf D 6(p VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 DESIGN &DEVELOPMENT DEPARTMENT FAX (760) 777-7011
INSPECTIONS (760) 777-7153
BUILDING PERMIT
Permit Type/Subtype: BUILDING COMMERCIAL/REMODEL
Application Number: BCOM2018-0046 Owner: Date: 4/5/2019
Property Address: 51230 EISENHOWER DR VPAH
APN:773072019 P 0 BOX 1711 Application Description: VILLAGE PARK ANIMAL HOSPITAL/ (2) DRYER DUCTS & HOSE BIB LA QUINTA, CA 92253
Property Zoning:
Application Valuation: $4,000.00
Applicant:
DR KATHRYN CARLSON D Contractor:
OWNER BUILDER
51230 EISNHOWER DR
LA QUINTA, CA 92253 APR 0 5 2019
I
CITY OF LA QUINTA
DESIGN & DEVELOPMENT DEPARTMENT Llc. No.:
LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARgTlON
I hereby affirm under penalty of perjury that l am licensed under provisions of Chapter I hereby affirm under penalty of perjury one of the following declarations:
9 (commencing with Section 70001 of Division 3 of the Business and Professions Code,
and
I have and will maintain a certificate of consent to self -insure for workers'
Licenssee Class: License No.: License is in full force and effect. compensation, as provided For by Section 3700 of the Labor Code, for the performance
z ❑f the work For wltleh this permit islssued.
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:
Carrl r: 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 3700 of the Labor Code, I shall forthwith
comply with those previsions.
Date: Applicant: ;
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.
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).:
.(]_f) I, 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.).
160 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 Contractors' State License Law.).
(_) I am exempt under Sec. B.&P.C. for this reason
Date: Owner:
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
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 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.
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
:onstruction, and hereby authorize representatives of this city to enter upon the
Ibove-mentioned property for inspection purposes.
C" 114
)ate: ]` ! 1 Signature (Applicant or Agent).
Application Number:
Property Address:
APN:
Application Description
Property Zoning:
Application Valuation:
Applicant:
DR KATHRYN CARLSON
51230 EISNHOWER DR
LA QUINTA, CA 92253
BCOM2018-0046
51230 EISENHOWER DR Owner:
773072019 VPAH
VILLAGE PARK ANIMAL HOSPITAL / (2) DRYER DUCTS &HOSE BIB P 0 BOX 1711
LA QUINTA, CA 92253
$4,000.00
Contractor:
OWNER BUILDER
Date: 4/5/2019
- -- - ----- - - -- - ----- ----
LIC. No.:
Detail: VILLAGE PARK ANIMAL HOSPITAL. / RE -RUN (2) DRYER DUCTS FROM EXISTING LAUNDRYAREA TO ROOF. INSTALL LINT D
DRYERS AND NEW HOSE BIB AT ROOF. 2016 CALIFORNIA BUILDING CODES. DETECTION SYSTEM AT
rimatUrim IIUCnDRAATInA1
DESCRIPTION
Credit Card Fee
ACCOUNT QTY AMOUNT
101-0000-43505 0 $2.25
Total Paid for Credit Card Fee: $2.25
DESCRIPTION
ACCOUNT
QTY
AMOUNT
$101.40
101-0000-42600
ACCOUNT
($40.02)
DESCRIPTION
ACCOUNT
QTY
AMOUNT
( $13.34)
101-0000-42600
ACCOUNT
($40.02)
DESCRIPTION
ACCOUNT
QTY
AMOUNT
OTHER MECHANICAL EQUIPMENT
101-0000-42402
0
$40.02
DESCRIPTION
ACCOUNT
QTY
AMOUNT
OTHER MECHANICAL EQUIPMENT PC
101-0000-42600
0
$40.02
I Total Paid for MECHANICAL: $0.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$101.40
Total Paid for PERMIT ISSUANCE: $101.40
DESCRIPTION
ACCOUNT
QTY AMOUNT
PLAN CHECK DEPOSIT - ADDITION/REMODEL
101-0000-42600
1 $125.00
Total Paid for PLAN CHECK DEPOSIT - ADDITION/REMODEL: $125.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
101-0000-42600
0
( $13.34)
DESCRIPTION
ACCOUNT
QTY
AMOUNT
101-0000-42600
($13.34)
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WATER SYSTEM INST/ALT/REP
101-0000-42401
0
$13.34
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WATER SYSTEM INST/ALT/REP PC
101-0000-42600
0
$13.34
Total Paid for PLUMBING FEES: $0.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
101-0000-42600
($13.28)
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RECORDS MANAGEMENT FEE - MAJOR
101-0000-42416
0
$7.72
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RECORDS MANAGEMENT FEE - MAJOR
101-0000-42416
0
$13.28
Total Paid for RECORDS MANAGEMENT FEE - MAJOR: 57.72
DESCRIPTION
ACCOUNT
QTY
AMOUNT
101-0000-42600
($5.00)
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $0.00
+� Qwll�traPERMIT
#4��;+V
PLAN LOCATION:
Project Address: Si a3b E_15r_ t j I4)ky f
Project Description: Pool, Remodel, Add't, Elect, Plumb, Mech
APN #:
Garage SF
Telephone:
Koo
Applicant Name:
Email:
Address: �U C -s ;C-�J I �LS1�>��
T G _13e-
City, ST, Zip: LA 62o::�" N CA J?�- 53
m,,c isTi/aG
Telephone: _76o - Lk ci' -• 5 1 t
Email:, N) C_ 8 / A4 C)D , C0
Valuation of Project $ 4
(' C:�VN'VG- . `3kJ36 -T-rT X766-31-17-- 101-Y-7
Contractor Name:
Address:
(8(4�
sup
New SFD Construction:
Conditioned Space SF
City, St, Zip
5)�� ��
Garage SF
Telephone:
Patio/Porch SF
Email:
Fire Sprinklers SF
State Lie:
City Bus Lie:
Arch/Eng Name:
Address:
City, St, Zip
Telephone:
Email:
State Lie:
City Bus Lie:
Construction Type:
Grading:
Bedrooms:
Occupancy:
Stories: # Units:
Property Owner's Name: r R WA- AF,��/_) CPKuS-,J
New Commercial / Tenant Improvements:
Address:
Total Building SF
City, ST, Zip
Construction Type: Occupancy:
Telephone:Y�9y S
Email: (<c0o& D6 cls / ARoo , c6&+A
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
OFFICE USE ONLY
#
Submittal
Req'd
Ree'd
Plan Sets
Structural Cates
Truss Calcs
Title 24 Calcs
Soils Report
Grading Plan (PM 10)
Landscape Plan
Subcontractor List
Grant Deed
HOA Approval
School Fees
Burrtec Debris Plan
Planning approval
Public Works approval
Fire approval
City Business License
T44f 4 4 a"
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(7 60) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
1EXPORTANTl 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 the property
improvements specified at 'Sl -;, o zL,5cn. ��i o
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 signr�you understand or verify this information.
. 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.
AcI understand building permits are not required to be signed by property owners unless they are responsible for the
ction and are not hiring a licensed Contractor to assume this responsibility.
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 Iicensed Contractor and having the permit filed in his or her name instead of my
own.
�
sI understand Contractors am required by law to be licensed and bonded in California and to list their license numbers on
p and contracts.
�I understand if I employ or otherwise engage any persons, other than California licensed Contract
ors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
ttnd�rr 'state and federal law.
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
`ris .
1 . I understand under California Contractors' State License Law, an Owner -Builder who builds single -Family residential
structures cannot Iegally 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.
*na
. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
ior personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
wor nship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
�ervice, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division f Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at I-
81
-
800-32 CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
*arty'
egally and financially responsible for proposed construction activity at the following address:
\\
1. I agree that, as the party legally a�fd financially responsible for this proposed construction activity, I will abide by all
applicable ws and requirements that govern Owner -Builders as well as employers.
. 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 Contactors 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 f - Date: (/� Cwt/ l
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. p U�-�->' (Jq j�-(Z CT, J(l
Scope of Construction Project (or Description of Work): I��C ��`��`� S g
Project Location or Address: S*! " )-3o C,C-�l1`bw
Name of Authorized Agent: D �%��61_f� Tel No �i6o 3C - /T?
Address of Authorized Agent: J SS �� 40 �
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. N te: A copy of the owner's driver's license, form notarization, or other verification
acceptable to the agency is req red be presented when permit is issued to verify the property owner's signature.
Property Owner's Signatur Date: '/
R -A4) CAC-clC Scots av jg-W-ib
Sr a3� — CITY OF LA Q.UINTA SUB -CONTRACTOR LIST
JOB ADDRESS C—�Lsc--�F-�w�->� PERMIT NUMBER OWNER to ; Pw �. a BUILDER
TI7is form shall _be Rosted on the job with the Building -ins ectinn Card at afl times in a canspicuousplace, Only persons appearing on this list or their employees are authorized to work
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 building permit. For each applicable trade, all information
requested
below must be completed ley applicant. "On File" is not an acceptable response.
Trade.:I -I catjort..- .. Cnhtrac[crr
State-Cdntractoi's.•License
---
Vlvor�):rs: C?mpe..risation •I.n..surance
_ City 8u.siness
License
License Number
(xxxx)
'-Exp. Date
(xx/xx/xx)
Company Name
Classification
(e.g. A, B, C-8)
License Number Exp. Date Carrier Name Policy Number
(xxxxxx) (xx/xx/xx) (e.g_ State Fund, CalComp) (Format Varies)
Exp. Date
(xx/xx/xx)
EARTHW RK (G-12) —"
CONCRETE: (:C=B)
:FRAMING; (C-5): e
STRUCT. STEEL (C=51:): —`
MASONRY (C29:)
PLUMBING (C-36)
:LATH,. PLASTER. (:C-3.5)
:DRYWALL (C;9)
HVAC (C-20) -
C
- :,(FI s4c- Ic- c� rut 05 t
1
ELECTRICAL (C-' M —
ROOFING (C•39) AL,
-3 6
-731 gy S i -3l -i� %1PPt,:10 0"ERI 106 -3 8 Sl 6 10 10,6
Y_
cr,ol- i9
ciao146
0000106—
5-31-11
SHEET 1yTTAL (C-43): —
FL,OORI NG (0=15) —
GLAZ.IN:G T'C717>):
INS.UL:ATIO:N::(C:21
SEWAGE DISP. (C-42) --
PAINTING (C-33) --
CERAMIC TILE (C-54) ^"
CA:61NETs (C-6)
FENCING (C43)
LANDSCAPING (C-27)'
pOQL-.(C-..-53)
See
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SuILvING DIVISION
REVIEWED
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RECEIVED
MAR 2 12019
CITY OF LA QUINTA
COMMUNITY DEVELOPMENT
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