BELC2020-0001wih
78-495 CALLE TAMPICO 0 4P
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype: ELECTRICAL/
Application Number: BELC2020-0001
Property Address: 51955 AVENIDA DIAZ
APN: 773155022
Application Description: JAKOBSEN / AMP MAIN BREAKER CHANGEOUT
Property Zoning:
Application Valuation: $600.00
Applicant:
a
M. DOROTHY JONES
51955 AVE NIDA DIAZ JAN 0 2 2020
LA QUINTA, CA 92253 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
a I I ege4 exemption. Any violatian of Section 7031.5 by any applicant for a permit
cts the applicant to a civil penalty of not more than five hundred dollars [$500).:
4in) I, as owner of the property, or my employees with wages as their sole
co pensation, will do the work, and the structure is not intended or offered for 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
withly neYear
of Completion, the owner -builder will have the burden of proving that he
e did not build or improve for the purpose of sale.).
[ ) I, as owner of the property, am exclusively contracting with licensed contractors to
co ruct 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: I I �- s 0 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 Address:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 1/2/2020
Owner:
ROBERTJAKOBSEN
2216 SPARKLING
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:
Car - Policy Number:_
1 certify that in the performance of the work for which this permit is issued, I
shal no 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 Witt thos provislons.
Date: I I S I k 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.
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 pe. n It 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 t nter upon the above -
mentioned rope ty for inspection purposes.
Date: `Signature (Applicant or Agent): at,
Date: 1/2/2020
Application Number:
Property Address:
APN:
Application Description:
Property Zoning:
Application Valuation:
Applicant:
M. DOROTHY JONES
51955 AVENIDA DIAZ
LA QUINTA, CA 92253
BELC2020-0001
51955 AVENIDA DIAZ
773155022
JAKOBSEN / AMP MAIN BREAKER CHANGEOUT
$600.00
Owner:
ROBERTJAKOBSEN
Contractor:
OWNER BUILDER
Llc. No.:
Detail: 200A ELECTRICAL SERVICE CHANGE OUT [200A EXISTING] THIS PERMIT DOES NOT INCLUDE RELOCATION OF EQUIPMENT. 2016 CALIFORNIA
BUILDING CODES.
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
QTY
AMOUNT
SERVICES PC
101-0000-42600
0
$13.42
Total Paid for ELECTRICAL 2019: $40.25
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$101.97
Total Paid for PERMIT ISSUANCE: $101.97
DESCRIPTION
ACCOUNT
QTY
AMOUNT
RECORDS MANAGEMENT FEE
101-0000-42416
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
4 Quixra
PERMIT #
+ PLAN LOCATION:
Project Address: 71v&,u D j(4 a L4TProject Description: Pool, Remodel, Add't, Elect, Plumb, Mech
APN #:
Applicant Name: M , d }-ol N' 0�
Address:
City, ST, Zip: �� 2�7
Telephone: -
Email:
Valuation of Project S
Arch/Eng Name: Construction Type: Occupancy:
Address: Grading:
City, St, Zip
Telephone: Bedrooms: Stories: # Units:
Email:
State Lic: City Bus Lic:
Property Owner's Name:
Address: 51 q qJ1
City, ST, Zip La h
Telephone: �� _
Email: -
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
Tibf
44"
P.Q. BOX 1504
LA QUINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT
78-495 CALLS TAMPICO (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
PROPERTY OWNER'S PACKAGE
Disclosures & Forms for Owner -Builders Applying for Construction Permits
1-W )RT.i.w'! NOTWE -In f'It[.3PERTY OWNER
Dear Property Owner:
An application for a building Prmlit has been submitted
improvements specified at f �— your name listing yourself the builder of the pro tty
We are providing Jib r-J- fowled G'�/L 1 CALL�iv� (' ► 5
P g you with an wncr-Builder Acknowledgment and In urination Verification Farm W n7ak} e►r atvhre 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 trail you have read, Initialed your understanding of each provision,
SWIM? and returned this form to us at our official address indiested. An agent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the penrrritting authority
�erlU VERJFI(:ATIQN OF I,NIF'()RIXLATIUN
l t �x�: � `r'r��.�.; Rau,! cr+rrl,rritrrr! i•err l7 erurr+►rr+rr �+rla,v rr� s,�rltlt r•.rrr rr+rrl��•crrrrrrl err srri/r rlrl-, rul�,rmalialt.
�1. [ understand a trN"Cltr practice of unlicensrii persons is to have the property
building permit that erroncnuiI Y implies that thoc
e prperly owner is providing his or herr own labor and material prsonaIlyraldes
an [honer -Builder, may be held liable and subject to serious financial nsk tear any injuries sustained by an unItcen.im person
and his or her employees while working on my property. My lta,nlet) w ner's insurance may not I11 1,lr car;aLc for thaw
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.
-a2. I understand building permits are not required to be signed by property owners unless they are responsible for the
construction and arc not hiring a licensed Contractor to assume this responsibility,
E73. 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 licensed Contractor and having the permit bled in his or her name instead of my
own.
j94. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
E25. 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 c,m iclered an "employer"
under state and federal law.
RIC 1 understand if I am considered an "employer" under slate and federal law, I must register with the state and federal
y-overnnrent, u•Ithliom payroll taxes, provide workers' cOmpensation disability insurance, and contribute to unrrnploynlent
lattrrl+cas rtion Iilr each "employee." I also utu[irstattrl my tailurre to
r,abide by these laws may subject me to sertuus r1luncial
r�yk,
IU 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
slruoul 'K :annnt legally lzuild thorn spell the rnlcnl tct offer them for sale, unless all work is herftrinuA by licensed
-NItrrs and the otwIthrr a1f;41WILI es riots I11+1 exceed four within any calendar year, or all of rlie work is performed
under enah1r,14r +lrth a liccn•rd general huttditry t'tenrracanr.
S.ZI. 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.
OW-`). 1 understand I ma), obtain more inforntatnon regarding my obligations a% an "employer" from the Internal Revenue
Service, the United States Sntall Business Administration, the California Depanntent of Benefit Payments, and the California
Division of industrial Accidents. I also understand i may contact the California Contractors' State License hoard (C'S1.13) at 1-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
0.1 am aware of and consent to an U.aner-Builder building pernia applied for in my [tame, and understand that I am the
party legally and financially resp°.sihlr for proposed cctnstrucunn activity at the following address:
1 I - 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 govem Owner -Builders as well as employers.
—QPR. i a4nee to notify the issuer of this form immediately of any additions, deletions, or changes to any of the intorniahon 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 hay e a license, the Contractors' State License Roard 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 he held liable for damages. If you obtain a permit as Owner -Builder and wish to hire C'nntrac.tors,
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 hoilding 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 copv 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.
QignatureofProperty, -
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.
Ai TH4Rf"/.A"I'1()N OF AGFNT TO AUT ON PROPERTY OWi TICS BEHALF
Excluding the Notice to Property Owner, the execution of which l 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.
ppe'bfConstruction PrvjCc[ [or Description of Worms _&Y e-,
Name of Authorized AgentP.Avewl��
1
�Addrets of Authorized Agent: JL95- / Q
I declare under penalty of pequry 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 p ented the permit is issued to verify the property owner's signature.
Property Owner's Signature Date: