BWFE2019-018878-495 CALLE TAMPICO T-v�D
/ � VOICE (760) 777-7125 LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Permit Type/Subtype: WALL/FENCE/CITY STANDARD/PRE-APPROVED Owner:
Application Number: BWFE2019-0188 GWENDOLYN DIXON
Property Address: 78525 AVENIDA ULTIMO 78525 AVENIDA ULTIMO
APN: 770091003 LA QUINTA, CA 92253
Application Description: DIXON / 94LF GARDEN WALL
Property Zoning:
Application Valuation: $10,000.00
Applicant: Contractor:
DAKOTA MICHELON LLL/JJJ�,��`, OWNER BUILDER
78525 AVENIDA ULTIMO D
LA QUINTA, CA 92253
SEP 20 2019 '
CITY OF LA QUINTA 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 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).:
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.).
(�; 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: "1 17 u \q 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
Date: 9/20/2019
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: _
12 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 provisions.
Date: 2"� t� Applicant: 1
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 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 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.
y r
Date: r. f Signature (Applicant or Agent):
Date: `` 9/20/2019
Application Number:
BWFE2019-0188
Property Address:
78525 AVENIDA ULTIMO
APN:
770091003
Application Description:
DIXON / 94LF GARDEN WALL
Property Zoning:
Application Valuation:
$10,000.00
Applicant:
DAKOTA MICHELON
78525 AVENIDA ULTIMO
LA QUINTA, CA 92253
Owner:
GWENDOLYN DIXON
78525 AVENIDA ULTIMO
LA QUINTA, CA 92253
Contractor:
OWNER BUILDER
Llc. No.:
Detail: 94 LF OF 6' GARDEN WALL AROUND FRONT COURTYARD [CITY SPECIFICATIONS] THIS PERMIT INCLUDES ELECTRICAL FOR THE NEW MOTOR/GATE.
PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE
AREA BETWEEN THE BACK OF CURB AND ANY FENCING SHALL BE LANDSCAPED, HAVE A SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE
CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016 CALIFORNIA BUILDING CODES.
FINANCIAL INFORMATION
DESCRIPTION ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 10OLF
101-0000-42404
0
$53.67
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 100LF PC
101-0000-42600
0
$67.08
Total Paid for BLOCK WALL 2019: $120.75
DESCRIPTION
ACCOUNT QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306 0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEVICES, FIRST 20
101-0000-42403
0
$26.83
DESCRIPTION
ACCOUNT
CITY
AMOUNT
DEVICES, FIRST 20 PC
101-0000-42600
0
$26.83
Total Paid for ELECTRICAL 2019: $53.66
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RECORDS MANAGEMENT FEE
101-0000-42416 1
0
$10.00 !
Total Paid for 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
TOTALS:•0
Project Address:��
APN #: 0 ql of
Applicant Name: 114
Address: �drX,
City, ST, Zip:.
Tele honeI�
' lf IVILlef,,C61-1
Email: 9 Itgr)C1/XDi7,
Architect/Engineer Name:
Address:
City, St, Zip
Telephone:
Email:
State Lic: City Bus Lic:
Property Owner's Name: 61
Address: Y65d\s7 w.,I)
City, ST, Zip /,�I_
Telephone: 7/(/
Email:11War0011,W)KYJ)A
PE
W
PLAN LOCATION:
Project Description:
v
LF
Project Valuation $ ioC) OC)
Construction
Grading:
Bedrooms: I Stories:
Occupancy:
# Units:
n, New Commercial / Tenant Improvements:
V/ Total Building SF
5,3 Construction Type: Occupancy:
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
OFFICE USE ONLY
#
Submittal
I
Required
Received
Plan Sets
Structural Calcs
Truss Calcs
Title 24 Calcs
CVWD Fire Flow Letter
Soils Report
Grading Plan (PM10)
Landscape Plan
Subcontractor List
Grant Deed
HOA Approval
School Fees
Burrtec Debris Plan
Planning approval
Public Works approval
Fire approval
City Business License
Tlur 4 4 Q"
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 your name listing yourself as the builder of the property
improvements specified at
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
DIR
ECTIONS: Read and initial each statement below to signify you understand or verb 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. 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.
'k. 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.
3. I understand as.an "Owner -Builder" 1 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 her name instead of my
own.
�4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
145.1 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.
�_V_6. 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
risk.
7. 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 the work is performed
under contract with a licensed general building Contractor.
fi8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be field liable for any
nancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
A9. 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.csib.ca.gov for more information about licensed contractors.
A-10. 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 responsible for proposed construction activity at the following address:
A11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
lIcabie laws and requirements that govern Owner -Builders as well as employers.
X,e
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
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 issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or
other verification acceptable to the agency is requir be presented when the permit is issued to verify the property
owner's signature. �j
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. L
Scope of Construction Project (or Description of Work): oo� F of Vbfr kkll
Project Location or Address: 6 u t%v ��
Name of Authorized Agent: G Tel No T U1 l/ ° 6�V
Address of Authorized Agent: b tqA ue n d-p-, �
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 present d hen permit is issued to verify the property ow er's signature.
Property Owner's Signature: Date: 9 AZ
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CITY OF LA QUJJ JTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATA i W BY
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