BPLB2019-009978-495 CALLE TAMPICO C& p D e( Qu&'L
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype:
PLUMBING/
Application Number:
BPLB2019-0099
Property Address:
52293 EISENHOWER DR
APN:
773265013
Application Description:
ZARDENETA/SEWER CONNECTION
Property Zoning:
Application Valuation:
Applicant:
nil
ANNE IRENE ZARDENETA
I
JUL 0 5 2019
81162 FRED WARING DRIVE
#104
INDIO, CA 92201
CITY OF LA QUINTA
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 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
c Ms owner of the property, or my employees with wages as their sole
pen sation, 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
did not build or improve for the purpose of sale.).
s owner of the property, am exclusively contracting with licensed contractors
to On!,'
,uct 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.& .C. fo this r)aagon
CONSTRUCTION LENDING AG Cy
I here b firm under penalty of perjury that there is a struct n len[j g agency for
the performance of the work for which this permit is Issu c. 3097, Civ. C.).
Lender's Name:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 7/5/2019
Owner:
BRIAN FERGUSON
81162 FRED WARING DRIVE #104
INDIO, CA 92201
Contractor:
OWNER BUILDER
Llc. No.
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:
Carrien Policy Number:
ertify that in the performance of the work for which this permit is issued, I
ampal shoy any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that, if�.ati
Id become subject to the
worrkers' compensattion provisions of Section 37 of LaT ode1-s4all forthith
co with those rovisions. ; [
WARMING:'FAILURE TO SECURE WORKERS' COMPENSATIONr �OV GE NLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AN CIV INES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO HE 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 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.
I certify that I have read this application and state that the abavejnformation is correct.
I agree to comply with all city and county ordinances ands to la s relating to building
construction, and hereby authorize representatives of thi city to nter po
abo mentioned property for inspection purposes.
21
Fe APbHCant air AReii!
Lender's Address: I Iu
Date: i7/5/2G-'9
Application Number: BPLB2019-0099
Property Address: 52293 EISENHOWER DR
APN: 773265013
Application Description: ZARDENETA / SEWER CONNECTION
Property Zoning:
Application Valuation:
Applicant:
ANNE IRENE ZARDENETA
81162 FRED WARING DRIVE #104
INDIO, CA 92201
Owner:
BRIAN FERGUSON
81162 FRED WARING DRIVE #104
INDIO, CA 92201
Contractor:
OWNER BUILDER
Llc. No.:
i
Detail: ABANDON SEPTIC TANK AND FILL WITH SLURRY OR SAND, HOOK UP TO CITY SEWER. WATER BACKFLOW DEVICE MAY BE NEEDED UPON INSPECTION.
PER 2016 CALIFORNIA PLUMBING CODE.
DESCRIPTION
ACCOUNT CITY
AMOUNT
PERMIT ISSUANCE
101-0000-42404 0
$101.40
Total Paid for PERMIT ISSUANCE:
$101.40
DESCRIPTION
ACCOUNT
CITY
AMOUNT
BUILDING SEWER
101-0000-42401
0
$26.68
DESCRIPTION
ACCOUNT
CITY
AMOUNT
BUILDING SEWER PC
101-0000-42600
0
$18.68
Total Paid for PLUMBING FEES:
$45.36
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RECORDS MANAGEMENT FEE
101-0000-42416
0
$10.00
Total Paid for RECORDS MANAGEMENT FEE: $10.00
DESCRIPTION ACCOUNT CITY AMOUNT
TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
PJnt(,Qaigr(4,PERMIT #Ili 1-"L- ('�(,7�'CAI it ORMA
PLAN LOCATION:
Project Address:,6 p -2 9 Project Description:
A P N #: �� a �� Q� C� acyA,
Applicant Name:&WE
Address:
City, ST, Zip: l 2Win[
Telephoner _ 0
Email: ,��n C Q Valuation of Project $
Contractor Name: �C�3�r 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:
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
,r1ATE1� COACBELLA VALLEY WATER DISTRICT
P.O. BOX 1058, COACBELLA, CALIFORNIA 92236 (760) 398-2651
INVOICE Date:7/2/2019
SUBJECT: SANTA CARMELITA, 52293 EISENHOWER DR., LOT 2, LA QUINTA, LID 684050 (SCC FEE ONLY)
FERGUSON, BRIAN Project: 19-9920
81162 FRED WARING ST., #104 Project Date: 5/2/2019
Amount Due: $4,851.00
INDIO, CA 92201 GEO: 06-06-12-1
Planner: RUBEN MONTIEL
TO INSURE PROPER CREDIT, PLEASE RETURN THIS PORTION WITH
REMITTANCE AND INCLUDE THE PROJECT ON YOUR CHECK
rifjon Charge Amount Totalount
1.00 FF SCC-COLLECTION 1 $2,415.001 $2,415.00
1.00 FJ SCC-TREATMENT $2,436.001 $2,436.00
$4,851.00
SUBJECT: SANTA CARMELITA, 52293 EISENHOWER DR., LOT 2, LA QUINTA, LID 684050 (SCC FEE ONLY)
COACHELLA VALLEY WATER DISTRICT
P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-2651
Page 1
From: billpay@paymentus.com
Subject: Payment Confirmation
Date: Jul 2, 2019 at 4:39:43 PM
.: IZARDENETA@aol.com
Deaf ANNE 1 ZARDENETA,
We are pleased to confirm your paymem with Coachella Valley Water DiatrioL BelaN Is the summary of your
payment transaction. Your payment has been •1eceiJed and will be �st®dto your,&=uat. Thank you for ,your
oordinued relatlonship with Coachella Valtey Vllaler Aistrici.
Confirmation Number:
Payment Date:
Payment Amount:
Total Amount Charged:
Contact Information
First Name:
Middle Name:
Last Name:
ZIP code:
Daytime Phone Number:
Email Address:
Account Information
Payment Type:
Account Number:
Payment Method:
Payment Method Information
Card Type:
Card Number:
Card Holder Name:
519026406
Jul 2, 2019 4:39.40 PM
$4,831.00
$4,861.00
ANNE
ZARDENETA
92201
.17641N3-0139
IZARDENETA@AOL.COM
Planning and Engineering
PZ 19-9920
Credit Card
Visa
ANNE I ZARDENETA
T-df 4 4a"
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 been submitted in yoi name listing yourself as the builder of the property
improvements specified at, .� 4
We are providing you with an Owner -Builder Acknow ent and Information Verification Dorm 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 VF R1 F1CATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
I understand a frequent practice of unlicensed persons is to .have the property owner obtain an "Owner -Builder"
but g 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 my property.
,,, W. 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.
I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
rrf elf from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
p is and contracts.
I*0fVy
understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under 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
go5v rnment, 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
risk,
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
st ct es cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
su contractors 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.
I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
tin cial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
. I understand 1 may obtain more information regarding my obligations as an "employer" from the Internal Revenue
S&Vice, 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.
4_ 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 respon> ible for p�oposed construction activity at the following address:
f-1 � c._. E __ I n _ _.
. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
. I agree to notify the issuer of this form inuriediately 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 a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuin permit. Note: A copy of the property owner's driver's license, form notarization, or
other verification acceptable t the ag nrl
requ to be Pr ente when the permit is issued to verify the propertyowner's signature. 7 ,
1, Signature of property
ft S,'7-0(i
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 permit is issued to verify the property owner's signature.
Property Owner's Signature: __ _ Date: