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BELC2019-009878-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Permit Type/Subtype: Application Number: Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: ANNE IRENE ZARDENETA 52293 EISENHOWER DR LA QUINTA, CA 92253 ELECTRICAL/ BELC2019-0098 52293 EISENHOWER DR 773265013 `&tr 44Quurw DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT ZARDENETA / 200A ELECTRICAL SERVICE CHANGE OUT $1,500.00 VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 10/10/2019 Owner: BRIAN FERGUSON /ANNE IRENE ZARDENETA 52293 EISENHOWER DR LA QUINTA, CA 92253 Contractor: DPOWNER BUILDER OCT 10 2019 CITY OFLAQUINTA 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 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 aIIeged exemption. Any violation of Section 7031.5 by any applicantfor a permit cis 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 sate c ensation, will do the work, and the structure is not intended or offered far safe. (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 fv thin one year of completion, the owner -builder will have the burden of proving that he he did not buttd or Improve for the purpose of sale.). as owner of the property, arts exclusively Contracting with licensed contractors to ruct the project. (Sec. 7044, Business and ProfessionsCode: 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. forthir•�sa�� r CONSTRUCTION LENDIN ENCy I hereby affirm under penalty of perjury that ther s ranstru on ending a ncy for the performance of the work for which this permit is i c. 3C97, Civ. C.). Lender's Name: Lender's Address: WORKER'S COMPENSATION DECLARATION 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: r: Policy Number:_ �� ertify that in the performance of the work for which this permit is issued, I s all n rnploy any person in any manner so as to become subject to the workers' compensation laws of California, and a e tha if I should become subject to the workers' compensation provisions o ction 37 oflEhe�Labor Code, I shall hwith� comply with those provisions. l` WARNING: FAILURE TO SECURE WORKERS'COMPENSAT19,N COV£ GE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL ESAN CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000). IN ADDMVN 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 ofthis 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 a st to laws relating to building construction, and hereby authorize representatives this ity t n an theab e- m:enpedpiropertV for inspection purposes. (6 r S' nature (Applicant orAgen ): 2( c.Date:� 10/10/2019 Application Number: Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: ANNE IRENE ZARDENETA 52293 EISENHOWER DR LA QUINTA, CA 92253 BELC2019-0098 52293 EISENHOWER DR 773265013 ZARDENETA / 200A ELECTRICAL SERVICE CHANGE OUT $1,500.00 Owner: BRIAN FERGUSON / ANNE IRENE ZARDENETA 52293 EISENHOWER DR LA QUINTA, CA 92253 Contractor: OWNER BUILDER Llc. No.. Detail: 200A ELECTRICAL SERVICE CHANGE OUT NOT TO BE RELOCATED [100A EXISTING] THIS PERMIT DOES NOT INCLUDE RELOCATION OF EQUIPMENT. 2016 CALIFORNIA BUILDING CODES. FINANCIAL DESCRIPTION INFORMATION ACCOUNT CITY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT CITY AMOUNT SERVICES 101-0000-42403 0 $26.83 DESCRIPTION ACCOUNT CITY AMOUNT SERVICES PC 101-0000-42600 0 $13.42 Total Paid for ELECTRICAL 2019: $40.25 DESCRIPTION ACCOUNT CITY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $101.97 Total Paid for PERMIT ISSUANCE: $101.97 DESCRIPTION ACCOUNT CITY 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 PERMIT # PLAN LOCATION: Project Address: j �2 Project Description: Pool, Remodel, Add't, Elect, Plumb, Mech APN #: tfp siL� v-D Applicant Name: tq T (-e VI 2 Address: City, ST, Zip: �. Telephone: Valuation of Project $ Contractor Name:0710z� New SFD Construction: Address: Conditioned Space SF City, St, Zip Garage SF Telephone: Patio/Porch SF Email: Fire Sprinklers SF State Lie: City Bus Lie: Arch/Eng Name: Construction Type: Occupancy: Address: Grading: City, St, Zip Telephone: Bedrooms: Stories: # Units: Email: State Lie: City Bus Lie: Property Owner's Name: ` ew ercial /Tenant Improvements: Address:&/ f(,2 I e0l d-L �Cl (/ � Total Building SF City, ST, Z f- 9' Z z v / Construction Type: Occupancy: Telephone:7L) _fig Email: 78495 CALLE TAMPICO LA QUINTA, CA 92253 760-777-7000 OFFICE USE ONLY # Submittal Req'd Rec'd Plan Sets Structural Calcs Truss Calcs f Title 24 Calcs 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 Tw�t 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 (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 ermit has been submitted i your name listing yourself as the builder of the property improvements specified at J 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 signify you understand or verify this information. 41-understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" bueg 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. Qr__T_ 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. C-b: I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect m f 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 pe6&s and contracts. 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 considered an "employer" under state and federal law. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal g& ment, 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 s6adtfures 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. G : 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. 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 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. D. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the legally and financially responsible for proposed construction activity at the following address: �gree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all a ble laws 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 ha rovided 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 t ermit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to a age cy� -required to be -presented when the permit is issued to verify the property owner's signature. --\ 2 l�Signature of property owner w cf . - __� Date: 2 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: